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 B
Explanation
A. Formoterol is a long-acting beta agonist (LABA) used for maintenance therapy, not for aborting acute asthma attacks. LABAs help prevent asthma symptoms but are not effective for immediate relief during an acute attack.
B. Albuterol is a short-acting beta agonist (SABA), which is the medication of choice for relieving acute asthma symptoms. It acts quickly to relax the muscles of the airways and relieve bronchospasm.
C. Beclomethasone is an inhaled corticosteroid used for long-term asthma control, reducing inflammation, but it is not used to treat acute attacks.
D. Salmeterol is another LABA, similar to formoterol, and is not used for aborting acute asthma attacks but rather for long-term control.
Correct Answer is B
Explanation
A. While tissue integrity is important, the primary concern immediately postoperatively for a patient who has undergone a partial laryngectomy is ensuring that the airway is open and clear.
B. Airway patency should be assessed first because this surgery involves the upper airway structures, and complications such as obstruction, swelling, or bleeding could compromise the airway and lead to respiratory distress.
C. Pain severity should be assessed as part of routine care, but airway patency takes precedence to prevent respiratory complications.
D. Wound drainage should be monitored but does not take priority over airway assessment in the immediate postoperative period.
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