A 55-year-old woman entered the emergency room by ambulance. Her primary complaint is chest pain. She is receiving O2 via nasal cannula at 2 L/min for dyspnea. Which of the following findings in the client's nursing assessment demand immediate nursing action?

• A.Associated symptoms of indigestion and nausea
• B.Restlessness and apprehensiveness
• C.Inability to tolerate assessment session with the admitting nurse
• D.History of hypertension treated with pharmacological therapy

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Which of the following signs and symptoms indicates a tension pneumothorax as compared to an open pneumothorax?

• A.Ventilation-perfusion (V./Q.) mismatch
• B.Hypoxemia and respiratory acidosis
• C.Mediastinal tissue and organ shifting
• D.Decreased tidal volume and tachypnea

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A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:

• A.Bleeding, bruising, and hemorrhage
• B.Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
• C.Pain, pallor, pulselessness, paresthesia, and paralysis
• D.Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus

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A male client has experienced low back pain for several years. He is the primary support of his wife and six children. Although he would qualify for disability, he plans to continue his employment as long as possible.
His back pain has increased recently, and he is unable to control it with non-steroidal anti-inflammatory agents. He refuses surgery and cannot take narcotics and remain alert enough to concentrate at work. His physician has suggested application of a transcutaneous electrical nerve stimulation (TENS) unit. Which of the following is an appropriate rationale for using a TENS unit for relief of pain?

• A.TENS units have an ultrasonic effect that relaxes muscles, decreases joint stiffness, and increases range of motion.
• B.TENS units produce endogenous opioids that affect the central nervous system with analgesic potency comparable to morphine.
• C.TENS units work on the gate-control theory of pain; biostimulation therapy of large fibers block painful stimuli.
• D.TENS units prevent muscle spasms, decrease the potential for further injury, and minimize pressure on joints.

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A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:

• A.Call the physician
• B.Assess her vital signs
• C.Give the prescribed oxytocic drug
• D.Massage her fundus

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