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 A
Explanation
A. Elevate the head of the client's bed to 45° during meals: This is the correct action. Elevating the head during meals helps promote proper swallowing and reduces the risk of aspiration by preventing food or liquid from entering the airway. A semi-upright position is essential for clients at risk of aspiration, particularly those with dementia, who may have impaired swallowing reflexes.
B. Provide the client with oral hygiene: While important for oral health and to reduce bacteria in the mouth, this action does not directly reduce the risk of aspiration during meals. Oral hygiene is beneficial for preventing infections, but it doesn't influence the act of swallowing during eating.
C. Instruct the client to tilt their head back while swallowing: This is incorrect. Tilting the head back can cause difficulty in swallowing and increase the risk of aspiration. The correct technique is to maintain a neutral or slightly forward position of the head to allow food to travel smoothly down the esophagus and prevent it from entering the airway.
D. Turn on the television for the client during meals: This is not recommended as it can distract the client from focusing on eating. Distractions like a television may reduce the client's ability to concentrate on the swallowing process, increasing the risk of aspiration and choking.
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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