A middle-aged client reports, "I can't get my breath when I walk." Upon assessment, the nurse notes that the patient has a barrel chest and is using his accessory muscles to breathe. The patient's respiratory rate is 28/min. On palpation, there is limited expansion and decreased tactile fremitus. Percussion yields hyperresonant sounds. On auscultation, prolonged expiration, scattered wheezes, and rhonchi are present. Which disorder would the nurse suspect?
Pneumonia.
Atelectasis.
Pleural effusion.
Emphysema.
The Correct Answer is D
Choice A rationale:
Pneumonia is not likely to be the correct answer. Pneumonia is often characterized by productive cough, fever, chest pain, and increased tactile fremitus due to consolidation of lung tissue. The presence of barrel chest, decreased tactile fremitus, and hyperresonant percussion sounds is not consistent with pneumonia.
Choice B rationale:
Atelectasis is not the most likely option. Atelectasis refers to collapsed or partially collapsed lung tissue, which can lead to decreased breath sounds, dullness to percussion, and decreased tactile fremitus. The symptoms mentioned in the scenario, such as prolonged expiration, wheezes, and barrel chest, are not indicative of atelectasis.
Choice C rationale:
Pleural effusion is not the most suitable choice. Pleural effusion usually presents with decreased breath sounds, dullness to percussion, and decreased tactile fremitus over the affected area due to fluid accumulation in the pleural space. The hyperresonant percussion sounds and the presence of wheezes and rhonchi do not align with pleural effusion.
Choice D rationale:
Emphysema is the most likely disorder based on the given symptoms. Barrel chest (increased anterior-posterior chest diameter), limited lung expansion, decreased tactile fremitus, hyperresonant percussion sounds, prolonged expiration, wheezes, and rhonchi are characteristic findings of emphysema. This condition involves damage to the alveoli and their supporting structures, leading to air trapping, reduced lung elasticity, and obstructed airflow. The patient's use of accessory muscles to breathe further suggests a chronic obstructive pulmonary disease (COPD) like emphysema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Offering a glass of water to the patient is not a priority action when dealing with a surgical incision that eviscerates. This situation requires immediate intervention to prevent complications related to the evisceration.
Choice B rationale:
Monitoring the patient for signs and symptoms of shock is crucial in this scenario. Evisceration, the protrusion of organs from a surgical incision, can lead to significant blood loss, which may result in shock. Signs of shock include hypotension, tachycardia, pallor, diaphoresis, and altered mental status.
Choice C rationale:
Placing moist sterile gauze over the site is appropriate to prevent the exposed organs from drying out and becoming further damaged. It also helps to reduce the risk of infection. Moist sterile gauze helps maintain a sterile environment and prevents the organs from being exposed to contaminants.
Choice D rationale:
Gently placing the organs back into the abdominal cavity is not within the nurse's scope of practice. This action requires surgical intervention by a healthcare provider. The nurse's role is to provide immediate first aid and notify the surgeon.
Choice E rationale:
Contacting the patient's surgeon is essential. Evisceration is a surgical emergency, and the surgeon needs to be informed promptly to make decisions regarding further interventions. The patient may require emergency surgery to address the evisceration and prevent complications.
Correct Answer is D
Explanation
Choice A rationale:
Requiring the child to be free from nits before returning to school might not be an accurate understanding of the situation. Nits are the eggs of head lice and may remain attached to the hair even after effective treatment. The presence of live lice is a more crucial factor to consider.
Choice B rationale:
Throwing out toys that can't be dry cleaned or washed is an unnecessary and extreme measure. Head lice do not survive long away from the human scalp, so the risk of transmission through inanimate objects like toys is minimal. Thoroughly cleaning and vacuuming the environment is more effective.
Choice C rationale:
Treating all family members is indeed a prudent approach. Head lice can spread easily within households, especially among close contacts. Treating everyone helps prevent re-infestation and disrupts the lice life cycle.
Choice D rationale:
Washing recently used clothing, bedding, and towels in hot water is a correct understanding of how to manage head lice. The high temperature kills lice and their eggs. It is an essential step in preventing the spread of lice and re-infestation.
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