A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Abdominal retraction

Clubbing nails

Restlessness

Dependent edema 4+

Answer and Explanation

The Correct Answer is B

A.   Abdominal retraction is typically a sign of acute respiratory distress, not chronic respiratory insufficiency.
B.   Clubbing nails occurs as a chronic response to inadequate tissue oxygenation and is often associated with conditions like chronic obstructive pulmonary disease (COPD).
C.   Restlessness may occur during acute respiratory distress but is not a typical finding in chronic respiratory insufficiency.
D.   Dependent edema 4+ is more related to cardiac conditions such as heart failure rather than respiratory insufficiency, which generally results in more subtle signs like clubbing or cyanosis.

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Correct Answer is ["B","D","E","F"]

Explanation

A. The client has not received the pneumococcal vaccine, but pneumococcal vaccination would help prevent pneumonia, particularly from Streptococcus pneumoniae. However, because the client has nothad the vaccine, this option would be a risk factor for pneumonia, but it is not an immediate concern in terms of assessing the current risks in their medical record.
B. The client appears lethargic and has difficulty answering questions due to shortness of breath, which suggests a decrease in the level of consciousness. Decreased mental status or level of consciousness increases the risk of aspiration, which can lead to pneumonia. For example, an altered level of consciousness makes it harder for patients to protect their airways (e.g., coughing or swallowing properly), which may increase the risk of aspiration and subsequent infection.
C. The client has not received the influenza vaccine, which does increase the risk of contracting
pneumonia, especially if the person develops influenza. However, the patient’s primary issue is likely already in progress, so this is another unvaccinated status contributing to risk rather than an immediate finding.
D. The client’s medical history is notable for no significant conditions other than the acute issue at hand. However, the lack of a pneumococcal vaccine (despite being at higher risk due to age) and not receiving the annual influenza vaccination can contribute to the development of pneumonia. Pneumonia is more common in individuals who do not receive these vaccines, as they provide protection against common respiratory pathogens, including Streptococcus pneumoniae and influenza viruses.
E. The client reports decreased fluid intake over the past 24 hours due to a sore throat, which increases the risk of dehydration. Dehydration can lead to thicker mucus, making it more difficult to clear respiratory secretions. This increases the likelihood of bacterial growth and the development of pneumonia.
F. The client is 70 years old, which places them at higher risk for pneumonia. Older adults have a weakened immune system, and their respiratory function may not be as effective as in younger individuals, making it easier for infections such as pneumonia to take hold. Age is a significant risk factor for more severe respiratory infections.
G. There is no mention of smoking history in the social history provided, so it cannot be included as a risk factor for pneumonia in this case. Smoking is a known risk factor for respiratory infections, but since it isn’t specified here, we cannot assume it is relevant.

A. Tachycardia B. Dyspnea C. Constipation D. Atrophied nodular thyroid gland

Correct Answer is A

Explanation

A. Tachycardia is a common sign of hyperthyroidism, as elevated thyroid hormones increase heart rate and metabolic rate.
B. Dyspnea is not typically associated with hyperthyroidism; more commonly, hyperthyroid patients experience tachypnea (increased rate of breathing), but not necessarily dyspnea.
C. Constipation is more commonly associated with hypothyroidism, where metabolic slowing occurs.
D. Atrophied nodular thyroid gland is not typical of hyperthyroidism; a goiter (enlarged thyroid) is more commonly seen.

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A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","D","E","F"]

Explanation

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Explanation

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