Patho Patho #94

Question

A client diagnosed with deep vein thrombosis suddenly complains of chest pain and shortness of breath and is visibly anxious. The nurse should immediately assess the client for signs and symptoms of?

Answers

  1. Pneumonia
    • Rationale:

      This answer choice is not correct as pneumonia does not have an abrupt onset of chest pain and dyspnea. It is an infectious process that progresses gradually as the infection worsens.

  2. Pulmonary edema
    • Rationale:

      This answer choice is not correct as pulmonary edema would present with adventitious breath sounds as opposed to a sudden onset of chest pain and dyspnea. PE is the best answer as the client has an existing DVT which is the most common etiology for PE.

  3. Pulmonary embolism
    • Rationale:

      This answer is correct because reports of sudden onset of chest pain and shortness of breath indicate a possible PE in a client with an existing DVT.

  4. Myocardial infarction
    • Rationale:

      This answer choice is not correct because myocardial infarction presents with chest discomfort unrelieved by rest. PE is the best answer choice since the client has an existing DVT.

Overview

The focus of this question is asking the nurse to identify signs and symptoms of pulmonary embolism. Most pulmonary emboli originate as deep vein thrombosis (DVT), so clients with DVTs should always be monitored for signs of PE. W=A client with an existing DVT who reports a sudden onset of chest pain and dyspnea should be immediately assessed for further signs indicating a PE.

Explanation

Learning Outcomes

A pulmonary embolism is blockage of a major artery within the pulmonary circulation that has migrated to the lungs from another area within the body. Most PEs originate as DVTs within the lower extremities. Signs and symptoms of PE include sudden reports of shortness of breath,chest pain, hypoxemia, restlessness, and hemoptysis. Clients with an existing DVT reporting any of these manifestations should be immediately assessed for further signs of PE and the provider notified.

Test Taking Tip

Look for keywords in the stem of the question such as “sudden”. Also, the fact that the client has a DVT is another key indicator of the correct answer that should not be overlooked.

Video Rationale