Free NCLEX-RN Exam Braindumps (page: 8)

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Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?

  1. Distant breath sounds
  2. Increased heart sounds
  3. Decreased anteroposterior chest diameter
  4. Collapsed neck veins

Answer(s): A

Explanation:

(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.



Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?

  1. Distant breath sounds
  2. Increased heart sounds
  3. Decreased anteroposterior chest diameter
  4. Collapsed neck veins

Answer(s): A

Explanation:

(A) Distant breath sounds are found in clients with emphysema owing to increased anteroposterior chest diameter, overdistention, and air trapping. (B) Deceased heart sounds arepresent because of the increased anteroposterior chest diameter. (C) A barrel- shaped chest is characteristic of emphysema. (D) Increased distention of neck veins is found owing to right-sided heart failure, which may be present in advanced emphysema.



When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:

  1. In neurogenic shock, the skin is warm and dry
  2. In hypovolemic shock, there is a bradycardia
  3. In hypovolemic shock, capillary refill is less than 2 seconds
  4. In neurogenic shock, there is delayed capillary refill

Answer(s): A

Explanation:

(A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client ishypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good.



When evaluating a client with symptoms of shock, it is important for the nurse to differentiate between neurogenic and hypovolemic shock. The symptoms of neurogenic shock differ from hypovolemic shock in that:

  1. In neurogenic shock, the skin is warm and dry
  2. In hypovolemic shock, there is a bradycardia
  3. In hypovolemic shock, capillary refill is less than 2 seconds
  4. In neurogenic shock, there is delayed capillary refill

Answer(s): A

Explanation:

(A) Neurogenic shock is caused by injury to the cervical region, which leads to loss of sympathetic control. This loss leads to vasodilation of the vascular beds, bradycardia resulting from the lack of sympathetic balance to parasympathetic stimuli from the vagus nerve, and the loss of the ability to sweat below the level of injury. In neurogenic shock, the client is hypotensive but bradycardiac with warm, dry skin. (B) In hypovolemic shock, the client ishypotensive and tachycardiac with cool skin. (C) In hypovolemic shock, the capillary refill would be>5 seconds. (D) In neurogenic shock, there is no capillary delay, the vascular beds are dilated, and peripheral flow is good.



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Naveen Ahlam commented on November 29, 2024
Great stuff
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Isadora Guimarães commented on November 10, 2024
Very good to study
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Marydee commented on April 02, 2020
Just purchased, will see if it is the real deal. Will give a further update later!
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