A client with a history of lung cancer reluctantly comes to the clinic because of persistent hoarseness and a chronic cough. The client's respirations are labored when speaking and the capillary refill is 3 seconds. Which additional finding warrants intervention by the nurse?
Coarse breath sounds.
Rust colored sputum.
Unexplained fatigue.
Clubbed fingernails.
The Correct Answer is A
The client's history of lung cancer, persistent hoarseness, chronic cough, and labored respirations when speaking indicate potential respiratory complications. Coarse breath sounds may suggest the presence of airway obstruction or fluid accumulation in the lungs, which can be indicative of a worsening condition.
The nurse should intervene promptly by assessing the client's respiratory status further, providing appropriate respiratory support, and notifying the healthcare provider for further evaluation and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.
Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.
Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.
Correct Answer is D
Explanation
A) Incorrect- This test is used to assess for infection or inflammation and is not specifically related to monitoring diabetes insipidus.
B) Incorrect- This test is used to monitor blood sugar levels in individuals with diabetes mellitus, not diabetes insipidus.
C) Incorrect- While urine specific gravity can provide information about urine concentration, it is not the most important laboratory test to monitor in a client with diabetes insipidus. Serum sodium level is a more critical indicator of electrolyte balance and potential complications in DI.
D) Correct- Diabetes insipidus (DI) is a condition characterized by excessive thirst and urination due to the body's inability to regulate fluid balance. In DI, the body either lacks antidiuretic hormone (ADH), which regulates water reabsorption in the kidneys, or the kidneys are resistant to its effects. As a result, clients with DI can produce large volumes of dilute urine. The most significant concern in DI is the potential for electrolyte imbalances, particularly low serum sodium levels (hyponatremia). Excessive loss of water in the urine can lead to dehydration and concentration of the blood's sodium levels. This can result in neurological symptoms, such as confusion, seizures, and even coma. Monitoring the serum sodium level is crucial to ensure that it remains within a safe range.
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