A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?
Hypertension
Unequal pupils
Confusion
Tympany upon chest percussion
The Correct Answer is C
A. Hypertension is not typically associated with pneumonia, especially in older adults. Pneumonia can lead to hypotension or sepsis, but not usually hypertension.
B. Unequal pupils are not a typical finding associated with pneumonia. This could suggest a neurological issue or a possible eye problem, not a respiratory infection.
C. Confusion is a common sign of pneumonia in older adults, especially in the elderly, who may present with altered mental status due to hypoxia, infection, or dehydration. Delirium or confusion is a common manifestation of pneumonia in this population.
D. Tympany on chest percussion suggests air in the abdominal cavity, not in the lungs, and is not typically associated with pneumonia. Pneumonia is more likely to present with dullness upon percussion due to consolidation in the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blistering burns are not a typical side effect of radiation therapy for laryngeal cancer. Radiation burns can occur on the skin, but they are more likely to cause irritation and redness rather than blistering burns, especially in the case of internal radiation targeting the larynx.
B. Diarrhea is a common side effect of radiation therapy when the abdominal or pelvic areas are treated, but it is not typically associated with radiation therapy to the larynx.
C. Dry mouth (xerostomia) is a common side effect of radiation therapy for laryngeal cancer, as the salivary glands may be affected by the radiation. This results in reduced saliva production, leading to a dry mouth.
D. Nausea is not a typical side effect of radiation therapy for laryngeal cancer specifically, though it may occur if other areas (such as the stomach) are being treated. Nausea is more commonly associated with chemotherapy.
Correct Answer is A
Explanation
A. Obtain a prescription for supplemental oxygen: This is the correct answer. The patient is experiencing hypoxia, and ensuring adequate oxygenation is the priority. Oxygen supplementation is essential to correct the hypoxia, which can exacerbate metabolic disturbances like diabetic ketoacidosis (DKA). Improving oxygenation will also support other treatments, such as insulin administration, by improving tissue perfusion.
B. Obtain a prescription to administer insulin: While insulin is a key treatment for DKA, addressing hypoxia first is more urgent. Hypoxia can impair the effectiveness of insulin and other therapies, so stabilizing the patient’s oxygen levels should be prioritized before insulin administration.
C. Obtain a prescription to administer intravenous fluids: Administering fluids is important in DKA management, especially for rehydration and correcting electrolyte imbalances. However, addressing hypoxia first is the priority to stabilize the patient and ensure optimal perfusion for further interventions like fluid resuscitation.
D. Obtain a prescription to check the client's glucose level: This is not necessary, as the glucose level is likely already elevated, which is characteristic of DKA. The focus should be on stabilizing the patient's airway and oxygenation before monitoring glucose levels or starting insulin.
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