A nurse is caring for a client who has COPD.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Cloudy effluent is one of the earliest and most specific signs of peritonitis. It warrants immediate evaluation and diagnostic testing to confirm the diagnosis and initiate appropriate treatment.
A Generalized abdominal pain is a common symptom of peritonitis but may not be the earliest indication.
B. Tachycardia (increased heart rate) can occur in response to infection or inflammation, including peritonitis. It is a systemic response rather than a localized symptom.
D. Fever can also be associated with peritonitis but may appear later and is not as specific early indicators
Correct Answer is B
Explanation
B. Photophobia, or sensitivity to light, is a common symptom in clients with meningitis. It occurs due to irritation of the meninges and the optic nerve by the inflammatory process. Clients may avoid bright lights and prefer dimly lit environments to reduce discomfort.
A Bradycardia (slow heart rate) is not typically associated with meningitis. In fact, many clients with meningitis may present with tachycardia (fast heart rate) due to fever, dehydration, and systemic inflammation. Therefore, bradycardia is not an expected finding in meningitis.
C. Petechiae (small red or purple spots) on the chest can occur in bacterial meningitis, particularly in cases caused by Neisseria meningitidis. These petechiae are often seen in clusters and can indicate disseminated intravascular coagulation (DIC), a serious complication associated with meningococcal infection. However, they are less specific
D. Headache is a hallmark symptom of meningitis, typically described as severe and persistent. It is often accompanied by other symptoms such as fever, neck stiffness (nuchal rigidity), photophobia, and altered mental status. Headache in meningitis is usually continuous rather than intermittent.
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