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 correct answer is choice d. Explain to the parents that anger is a common response to grief.
Choice A rationale:
Referring the parents to the chaplain for grief counseling can be beneficial, but it may not address the immediate emotional outburst and the need for understanding their feelings.
Choice B rationale:
Telling the parents that blaming each other will not change the situation might be true, but it can come across as dismissive and may not provide the emotional support they need at that moment.
Choice C rationale:
Assuring the parents that a terminal diagnosis is inevitable does not address their current emotional state and may seem insensitive to their grief and anger.
Choice D rationale:
Explaining to the parents that anger is a common response to grief helps them understand their emotions and provides immediate emotional support, making it the best intervention in this situation.
Correct Answer is B
Explanation
It is important for the nurse to clarify the client's goals for hospitalization, including the client's understanding of the role of radiation therapy in palliative care. The nurse should also assess the client's understanding of the potential benefits and risks of radiation therapy and communicate this information to the healthcare provider.
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