A nurse is performing a lung assessment on an older adult client and notes the following:

- Blood pressure: 136/90

- Pulse: 88 beats per minute

- Oxygen saturation: 92%

- Respiratory rate: 18 breaths per minute

- Lung sounds: Diminished breath sounds in all lung fields

What would the nurse expect to be happening with the client?

Client is experiencing a fluid deficit.

Adventitious sounds are present.

Hyperinflation of the lungs.

Client has a pectus carinatum.

Answer and Explanation

The Correct Answer is C

A. A fluid deficit may cause tachycardia and hypotension, but it does not directly cause diminished lung sounds.
B. Adventitious sounds (wheezes, crackles, rhonchi, etc.) are absent in this case. Diminished breath sounds suggest poor airflow, not abnormal sounds.
C. Hyperinflation of the lungs is correct. In conditions like chronic obstructive pulmonary disease (COPD) or emphysema, lung expansion is limited, leading to diminished breath sounds in all lung fields due to air trapping. The oxygen saturation of 92% is consistent with chronic lung disease.
D. Pectus carinatum (protrusion of the sternum) is a congenital deformity that does not cause diminished breath sounds.

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Correct Answer is B

Explanation

A. Hypoglycemia is not a primary cause of dehydration, though it can contribute to other symptoms.
B. Asking about diuretic medications is correct because diuretics increase urine output, which can lead to fluid loss and dehydration, particularly in older adults who may not adequately compensate with fluid intake.
C. The types of food purchased can influence hydration status but are not a primary factor in acute dehydration.
D. Over-the-counter supplements may have effects on hydration, but they are not the most immediate concern when assessing risk factors for dehydration.

A. "Lungs clear to auscultation bilaterally." B. "High school diploma plus 2 years of college." C. "Caregiver reliable source of information." D. "Menarche at age 13."

Correct Answer is D

Explanation

A. "Lungs clear to auscultation bilaterally" is a physical assessment finding and should be documented in the physical examination, not the review of systems (ROS).
B. "High school diploma plus 2 years of college" is part of the social history, not the ROS.
C. "Caregiver reliable source of information" pertains to the history's reliability or source of information, not the ROS.
D. "Menarche at age 13" is correct because the ROS consists of subjective information reported by the client regarding different body systems, including the reproductive system.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

Correct Answer is B

Explanation

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?

Correct Answer is D

Explanation

During the interview the client states, "Is today the 12th? My wife died two months ago today." Which of the following responses would be most appropriate?

A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

The nurse is providing health education to an elderly client with dysphagia following a recent ischemic stroke. What would be most appropriate for the nurse to include in the education?

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

The nurse is assessing vital signs on a client admitted to the medical-surgical unit. What is the correct technique for assessing the radial pulse?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?