A nurse is caring for a client diagnosed with advanced COPD. The nurse should anticipate which assessment findings when caring for clients with advanced COPD? (Select all that apply.)
Elevated temperature.
Pursed-lip breathing.
Clubbing of the fingers.
Concave chest.
Dyspnea at rest.
Correct Answer : B,D,E
A. Elevated temperature: Elevated temperature is not typically associated with advanced COPD unless there is an underlying infection. Infections such as pneumonia may exacerbate COPD symptoms but are not universal findings in advanced COPD.
B. Pursed-lip breathing: Pursed-lip breathing is a common compensatory mechanism seen in clients with COPD. It helps to slow down the rate of expiration and prevents alveolar collapse, improving gas exchange.
C. Clubbing of the fingers: Clubbing of the fingers is not typically associated with COPD. It is more commonly seen in conditions such as chronic hypoxemia, congenital heart disease, and certain lung diseases like bronchiectasis.
D. Concave chest: In advanced COPD, the chest may appear hyperinflated with a barrel-shaped chest due to air trapping. The presence of a concave chest is not characteristic of COPD.
E. Dyspnea at rest: Dyspnea, or difficulty breathing, is a hallmark symptom of COPD. In advanced stages, clients may experience dyspnea even at rest due to severe airflow limitation and impaired gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Dyspnea: Worsening dyspnea may indicate complications such as heart failure or embolization of infectious material to the lungs, which can occur in infective endocarditis as a result of vegetation formation on heart valves. Dyspnea can suggest decreased cardiac output or pulmonary involvement, indicating a worsening condition.
B. Malaise: Malaise is a nonspecific symptom that is common in infective endocarditis due to systemic infection and inflammation. While it can be present in both mild and severe cases, it may not specifically indicate worsening of the condition without other signs of deterioration.
C. Fever: Fever is a hallmark symptom of infective endocarditis and may persist or worsen with progressive infection. However, fever alone may not necessarily indicate worsening if the client is already febrile due to the underlying infection.
D. Anorexia: Anorexia or loss of appetite can occur in infective endocarditis due to systemic illness but may not specifically indicate worsening without other signs of deterioration. It is important to assess for other signs of worsening condition, such as hemodynamic instability or embolic events, in conjunction with anorexia.
Correct Answer is ["A","B","D","E"]
Explanation
A. Encouraging mouth care before and after meals helps maintain oral hygiene, which is essential for appetite stimulation and preventing oral infections.
B. Monitoring the client for changes in mental status is important as malnutrition can lead to cognitive impairment and changes in mental status.
C. Assessing the client's laboratory work for increased calcium levels may not be directly related to malnutrition due to cancer. Elevated calcium levels are more commonly associated with conditions like hyperparathyroidism or certain cancers, but it's not typically a direct consequence of malnutrition.
D. Advising the client to keep a food diary helps track food intake, identify any patterns related to malnutrition, and guide dietary interventions.
E. Instructing the client to drink extra fluids between meals helps prevent dehydration, especially if the client's intake is compromised due to malnutrition or cancer-related treatments.
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