A nurse in a provider’s office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
Narrowed pulse pressure
Night sweats
Bradycardia
Confusion
The Correct Answer is D
Choice A reason: Narrowed pulse pressure is not a specific manifestation of pneumonia in the older adult client. Pulse pressure is the difference between the systolic and diastolic blood pressure readings. A normal pulse pressure is about 40 mm Hg, and a narrowed pulse pressure is less than 25 mm Hg. A narrowed pulse pressure can indicate various conditions, such as heart failure, shock, or aortic stenosis, but it is not a sign of pneumonia.
Choice B reason: Night sweats are not a common manifestation of pneumonia in the older adult client. Night sweats are episodes of excessive sweating during sleep that can soak the bedding or clothing. Night sweats can have many causes, such as menopause, infections, medications, or cancer, but they are not typically associated with pneumonia.
Choice C reason: Bradycardia is not a usual manifestation of pneumonia in the older adult client. Bradycardia is a slow heart rate, defined as less than 60 beats per minute. Bradycardia can be normal in some people, such as athletes or those who are very fit, or it can be a sign of a problem with the heart's electrical system. Pneumonia does not cause bradycardia, but it can cause tachycardia, which is a fast heart rate, due to the increased oxygen demand and inflammation.
Choice D reason: Confusion is a frequent manifestation of pneumonia in the older adult client. Confusion is a state of impaired awareness, orientation, memory, or judgment. Confusion can occur in older adults with pneumonia due to several factors, such as hypoxia, dehydration, electrolyte imbalance, fever, or infection. Confusion can also increase the risk of complications, such as aspiration, falls, or delirium. Therefore, the nurse should monitor the mental status of the older adult client with pneumonia and report any changes to the provider..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Overflow incontinence is not the type of urinary incontinence that the client is experiencing. Overflow incontinence occurs when the bladder is overfilled and cannot empty properly, causing frequent or constant dribbling of urine. It can be caused by a blockage in the urinary tract, such as an enlarged prostate or a kidney stone, or by a weak bladder muscle that cannot contract enough to empty the bladder.
Choice B reason: Urge incontinence is not the type of urinary incontinence that the client is experiencing. Urge incontinence occurs when the bladder muscle contracts involuntarily and causes a sudden and strong urge to urinate, followed by an involuntary loss of urine. It can be caused by an infection, a neurological disorder, or an overactive bladder.
Choice C reason: Stress incontinence is not the type of urinary incontinence that the client is experiencing. Stress incontinence occurs when the pelvic floor muscles or the urethral sphincter are weakened or damaged and cannot hold urine in the bladder when there is increased abdominal pressure, such as from coughing, sneezing, laughing, or exercising. It can be caused by pregnancy, childbirth, menopause, or surgery.
Choice D reason: Reflex incontinence is the type of urinary incontinence that the client is experiencing. Reflex incontinence occurs when the bladder muscle contracts without the sensation or control of the person, causing urine to leak without warning or awareness. It can be caused by nerve damage that affects the communication between the bladder and the brain, such as from a spinal cord injury, a stroke, or multiple sclerosis..
Correct Answer is B
Explanation
Choice A reason: Encourage the use of wide grip utensils. This action is not related to homonymous hemianopsia, but to the motor weakness or paralysis that may occur on the opposite side of the body after a stroke. Wide grip utensils can help the client hold and use them more easily.
Choice B reason: Remind the client to look for food on the left side of the tray. This action is appropriate because homonymous hemianopsia is a visual field loss on the same side of both eyes. A client who had a right sided stroke will have difficulty seeing the left side of their visual field. Reminding the client to look for food on the left side of the tray will help them eat more completely and prevent malnutrition.
Choice C reason: Provide a nonskid mat to alleviate plate movement. This action is not related to homonymous hemianopsia, but to the safety and stability of the client's eating environment. A nonskid mat can prevent the plate from sliding or falling off the tray.
Choice D reason: Encourage the client to use his right hand when feeding himself. This action is not related to homonymous hemianopsia, but to the motor weakness or paralysis that may occur on the opposite side of the body after a stroke. Encouraging the client to use his right hand can help him maintain his independence and function.
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