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 A
Explanation
Choice A rationale:
This statement indicates a need for further teaching. Synthetic clothing and woolen socks can generate static electricity, which poses a risk around oxygen due to its flammable nature. The client should be advised to wear cotton clothing and avoid synthetic fabrics to prevent static-related accidents.
Choice B rationale:
This statement is correct. Oxygen supports combustion, so ensuring visitors don't smoke near the client is crucial. However, it does not indicate a need for further teaching.
Choice C rationale:
This statement is incorrect. The client cannot determine the oxygen flow rate by visual inspection of the flowmeter. The flow rate should be set based on the healthcare provider's instructions, and this information should have been covered in the teaching.
Choice D rationale:
This statement indicates the client understands the potential cognitive effects of oxygen therapy and when to seek medical assistance. It does not necessarily indicate a need for further teaching.
Correct Answer is D
Explanation
Choice A rationale:
Applying petroleum jelly to the nares is not necessary in this situation. Oxygen therapy through a nasal cannula aims to deliver oxygen to the client's respiratory system. Applying petroleum jelly might interfere with the oxygen delivery and is not a standard practice.
Choice B rationale:
Removing the nasal cannula while the client eats reduces the oxygen supply during a time when the body's oxygen demand might increase due to the digestive process. It's important to maintain consistent oxygen therapy, even during meals.
Choice C rationale:
Attaching a humidifier bottle to the base of the flow meter is not necessary for oxygen therapy at 5 L/min via nasal cannula. Humidification is usually needed at higher oxygen flow rates to prevent drying of the mucous membranes.
Choice D rationale:
Securing the oxygen tubing to the bed sheet near the client's head is the correct action. This ensures that the tubing is not pulled or tugged during movement, maintaining a steady flow of oxygen. Placing it near the client's head prevents kinking or tangling of the tubing and allows the client to move without disrupting the therapy.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.