A Medical-Surgical nurse is performing an assessment on a client with a history of chronic obstructive pulmonary disease. Which of the following findings will the nurse most likely observe?
Unequal chest expansion.
Atrophied neck and trapezius muscle.
Increased tactile fremitus.
An anterior-to-posterior chest diameter ratio of 1:1.
The Correct Answer is A
Choice A rationale:
Unequal chest expansion is the correct choice. In a patient with chronic obstructive pulmonary disease (COPD), the airways are often narrowed and obstructed, leading to difficulty in moving air in and out of the lungs. This can result in unequal chest expansion during breathing, where one side of the chest expands less than the other. This finding is commonly observed in patients with COPD due to the imbalance in lung function between different areas of the lungs.
Choice B rationale:
Atrophied neck and trapezius muscle is not a typical finding in COPD. Muscle atrophy can occur in conditions of prolonged disuse or immobility, but it is not a characteristic manifestation of COPD itself.
Choice C rationale:
Increased tactile fremitus refers to increased vibrations felt on the chest wall during speech. This finding is more commonly associated with conditions that cause lung consolidation, such as pneumonia. In COPD, there is often air trapping and hyperinflation of the lungs, which would not lead to increased tactile fremitus.
Choice D rationale:
An anterior-to-posterior chest diameter ratio of 1:1 is not a typical finding in a healthy individual, let alone in a patient with COPD. In COPD, there is often an increase in the anterior-to-posterior chest diameter ratio, giving the chest a barrel-like appearance. This is due to the trapped air and hyperinflation of the lungs, which is characteristic of the disease.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A rationale:
Explaining to the client that he needs the protein in the milk and the beef is not an appropriate action. Understanding and respecting the client's religious and dietary preferences are essential. Orthodox Jewish dietary laws, known as kashrut, prohibit the consumption of certain foods, including the mixing of meat and dairy in the same meal. This response disregards the client's faith-based dietary restrictions.
Choice B rationale:
Allowing the AP to deliver the food tray to the client is not appropriate in this situation. The nurse is responsible for ensuring that the client's dietary needs and preferences are met, especially when there are religious considerations involved. Failing to accommodate the client's dietary requirements could lead to non-compliance and potential harm.
Choice C rationale:
Replacing the nonfat milk with apple juice does not address the client's religious dietary restrictions. While the change may avoid mixing meat and dairy, it still disregards the importance of providing a kosher meal. Kosher dietary laws encompass more than just avoiding meat and dairy combinations. It is important to provide a fully compliant kosher meal.
Choice D rationale:
Calling the dietary department and asking for a kosher tray is the appropriate action. A kosher diet adheres to specific rules and regulations, including the separation of meat and dairy products. To respect the client's faith and dietary needs, the nurse should ensure that the food provided aligns with kosher guidelines. This choice demonstrates cultural sensitivity and ensures the client's well-being.
Correct Answer is C
Explanation
Choice A rationale:
Fresh frozen plasma (FFP) is a component of blood used to replace clotting factors and is typically indicated for specific medical conditions like bleeding disorders or massive transfusions. In this case, the client requires red blood cells due to significant blood loss, so FFP alone is not the appropriate choice.
Choice B rationale:
Initiating an immediate blood transfusion without the client's consent is not ethically appropriate, especially considering the client's religious beliefs as a Jehovah's Witness. Respecting the client's autonomy and religious convictions is important.
Choice C rationale:
Asking the client to decide about the blood transfusion is the correct course of action. Since the client is able to respond to questions appropriately, they should be informed about their condition, the need for a blood transfusion, and the potential risks and benefits. This respects the client's autonomy while ensuring they have the necessary information to make an informed decision.
Choice D rationale:
Notifying the client's family immediately is not the best initial action. While involving the family is important, the client's own decision about the blood transfusion should take precedence, especially when they are conscious and able to make decisions for themselves.
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