A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

Dyspnea

Barrel chest

Deep respirations

Clubbing of the fingers

Bradycardia

Answer and Explanation

Correct Answer : A,B,D

These findings are expected to be assessed in a client who has emphysema, which is a type of chronic obstructive pulmonary disease (COPD) characterized by destruction and enlargement of alveoli, loss of elastic recoil, and air trapping. These changes impair gas exchange and oxygenation, leading to chronic hypoxia and hypercapnia.

a) Dyspnea, or difficulty breathing, is a common symptom of emphysema, as the client has reduced lung capacity and increased work of breathing. Dyspnea may be worse with exertion, stress, or infection, and may cause anxiety and fatigue. The nurse should monitor the client's respiratory rate, rhythm, depth, and eﬀort, and provide oxygen therapy as prescribed.
b) Barrel chest, or increased anteroposterior diameter of the chest, is a physical sign of emphysema, as the client has chronic air trapping and hyperinﬂation of the lungs. Barrel chest may also cause kyphosis, or curvature of the spine, and reduced chest wall movement. The nurse should measure the client's chest circumference and observe for any deformities or asymmetry.
d) Clubbing of the fingers, or enlargement and rounding of the nail beds, is a late sign of emphysema, as the client has chronic hypoxia and tissue ischemia. Clubbing may also aﬀect the toes and ears, and may indicate pulmonary or cardiac disease. The nurse should inspect the client's nails for shape, color, angle, and capillary refill.

c) Deep respirations are not expected to be assessed in a client who has emphysema, as the client has shallow and rapid breathing due to air trapping and reduced lung compliance. Deep respirations may indicate other conditions, such as metabolic acidosis or anxiety. The nurse should assess the client's arterial blood gas levels and provide reassurance and relaxation techniques as needed.
e) Bradycardia, or slow heart rate, is not expected to be assessed in a client who has emphysema, as the client has tachycardia or normal heart rate due to hypoxia and increased sympathetic stimulation. Bradycardia may indicate other conditions, such as medication side eﬀects, vagal stimulation, or heart block. The nurse should monitor the client's pulse rate, rhythm, quality, and electrocardiogram as indicated.

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Correct Answer is D

Explanation

Answer: D. Cheyne-Stokes respirations

Rationale:

A) Stridor: Stridor is a high-pitched, wheezing sound resulting from disrupted airflow in the upper airway. It is not characterized by alternating periods of hyperventilation and apnea, making this choice incorrect.

B) Kussmaul respirations: Kussmaul respirations are deep, labored breaths typically associated with metabolic acidosis, such as diabetic ketoacidosis. These respirations do not exhibit alternating periods of hyperventilation and apnea, so this option is not applicable.

C) Apneustic respirations: Apneustic respirations are characterized by prolonged inhalation followed by a prolonged pause before exhalation. This pattern does not align with the alternating hyperventilation and apnea described, making it an incorrect choice.

D) Cheyne-Stokes respirations: Cheyne-Stokes respirations are characterized by a cyclical pattern of increasing depth and rate of breathing followed by a gradual decrease in depth and a period of apnea. This description matches the client's breathing pattern of alternating hyperventilation and apnea, making this the correct answer.

A. Encourage coughing and deep breathing B. Encourage regular use of the incentive spirometer C. Encourage the client to increase ﬂuid intake D. Encourage the client to ambulate frequently

Correct Answer is C

Explanation

Increasing ﬂuid intake helps to hydrate the mucous membranes and thin the respiratory secretions, which facilitates expectoration and improves gas exchange.

Encourage coughing and deep breathing. This is beneficial for clearing the airways and preventing atelectasis, but it does not directly aﬀect the viscosity of the secretions.
Encourage regular use of the incentive spirometer. This is helpful for expanding the lungs and preventing complications such as pneumonia or pleural eﬀusion, but it does not inﬂuence the consistency of the secretions.
Encourage the client to ambulate frequently. This is important for promoting circulation and mobility, but it does not have a significant eﬀect on the thinning of the secretions.

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A nurse is caring for a client who has emphysema. Which of the following findings should the nurse expect to assess in this client? (Select all that apply.)

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