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A nurse is caring for a client who has COPD.

Exhibits

Click to highlight the findings below that require immediate follow-up.

Body System Findings

Neurological

Day 1:
Neurological

Client is oriented to person, place, and time. Client is restless. Pupils are reactive to light. Able to move all extremities.

Pulmonary

Client is tachypneic, cough is productive, and mucous is yellow in color. Wheezes and crackles heard upon auscultation. Oxygen saturation 87% on room air.

Cardiovascular Pulse 110/min. +2 pulses in all extremities.

Client is restless

tachypneic, cough is productive

mucous is yellow

Wheezes and crackles

Oxygen saturation 87% on room air

Pulse 110/min

oriented to person, place, and time

Able to move all extremities

Answer and Explanation

The Correct Answer is ["A","B","C","D","E","F"]

Restlessness can be a sign of inadequate oxygenation to the brain, known as hypoxia. This is particularly concerning in a client with COPD whose oxygen saturation is already low (87% on room air).

These pulmonary findings indicate worsening respiratory distress in a client with COPD. Tachypnea, productive cough with discolored sputum, and abnormal lung sounds (wheezes and crackles) suggest exacerbation of COPD. The oxygen saturation of 87% on room air is below normal (typically 95% or higher), indicating hypoxemia, which requires immediate assessment and intervention to prevent further respiratory compromise.

The elevated heart rate (110/min) may indicate increased workload on the heart due to respiratory distress and hypoxemia.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A Structured activities are important for clients with Alzheimer's disease because they can help provide a sense of routine, purpose, and control. Engaging the client in meaningful activities that are simple and appropriate for their cognitive level can help prevent boredom, restlessness, and agitation.

B. Keeping the client's room dark during the day is not recommended as it can disrupt the client's sleep- wake cycle. Instead, maintaining a regular sleep schedule, promoting natural light exposure during the day, and ensuring a quiet, calm environment at night are more effective strategies.

C. While displaying a calendar can be helpful for some individuals with Alzheimer's, it doesn't directly address the need for structured activities or engagement throughout the day.

D. Providing excessive stimulation can overwhelm individuals with Alzheimer's disease. It's important to create a calm, predictable environment with familiar objects and routines to minimize confusion and agitation.

A. A client who has occasional urinary incontinence B. A client who has inadequate nutrition C. A client who has moderate Alzheimer's disease D. A client who is paraplegic

Correct Answer is D

Explanation

D. Paraplegia significantly increases the risk of skin breakdown due to immobility, lack of sensation, and prolonged pressure on specific areas of the body. These clients require meticulous skin care and frequent repositioning to prevent pressure injuries.

A While urinary incontinence can contribute to skin breakdown, especially if not managed properly, it may not pose as great a risk compared to other factors like poor nutrition or immobility.

B. Poor nutrition compromises skin integrity by reducing the skin's ability to repair and maintain itself, making it more susceptible to breakdown. This factor significantly increases the risk of developing pressure ulcers and other skin lesions.

C. Clients with Alzheimer's disease may have increased risk due to various factors such as mobility issues, impaired sensation, and difficulty with self-care. However, the degree of risk can vary depending on the stage of the disease and individual circumstances.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching for the family of a client who has Alzheimer's disease. Which of the following statements should the nurse include?

Correct Answer is A

Explanation

A nurse is assessing clients for skin integrity. Which of the following clients is at greatest risk for developing skin breakdown?

Correct Answer is D

Explanation

A nurse is preparing to administer intramuscular epinephrine to a client who is experiencing anaphylaxis. Which of the following sites should the nurse use?

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