An admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds. These findings indicated the nurse to monitor the client for what?

Kyphosis and clubbing of the fingers

Dyspnea and hypoxemia

Sepsis and pneumothorax

Bradypnea and pursed-lip breathing

Answer and Explanation

The Correct Answer is C

A. Kyphosis and clubbing of the fingers:

Kyphosis refers to an excessive forward curvature of the spine, which is not directly related to diminished breath sounds. Clubbing of the fingers is often associated with chronic respiratory conditions, but it is not directly linked to the finding of diminished breath sounds.

B. Dyspnea and hypoxemia:

Dyspnea (shortness of breath) and hypoxemia (low oxygen levels in the blood) are common symptoms in COPD, but diminished breath sounds may indicate an additional concern, such as pneumothorax or other complications.

C. Sepsis and pneumothorax:

Diminished breath sounds can be a sign of pneumothorax, a condition where air accumulates in the pleural space, leading to lung collapse. Sepsis is a risk in clients with COPD due to the potential for respiratory infections. Monitoring for these complications is crucial.

D. Bradypnea and pursed-lip breathing:

Bradypnea (slow breathing) and pursed-lip breathing are coping mechanisms that individuals with COPD may use to manage their breathing difficulties. While they are relevant in the context of COPD, they are not directly associated with the finding of diminished breath sounds.

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Correct Answer is A

Explanation

A. “I will need to stop smoking because the nicotine causes less blood to flow to my hands and feet.”

Explanation: This statement reflects an understanding of the association between smoking and reduced blood flow, particularly due to nicotine's vasoconstrictive effects.

B. “The older I get the higher my risk for peripheral arterial disease gets.”

Explanation: While age is a non-modifiable risk factor for PAD, it is not a statement indicating a change in behavior to address risk factors. It is correct information but doesn't involve a proactive approach to risk reduction.

C. “Since my family is from Italy, I have a higher risk of developing peripheral arterial disease.”

Explanation: Family history is a non-modifiable risk factor, and the statement correctly identifies this risk factor. However, it doesn't address modifiable factors or actions to reduce risk.

D. “I will need to increase the amount of green leafy vegetables I eat to lower my cholesterol levels.”

Explanation: This statement demonstrates an understanding of a dietary modification to lower cholesterol levels, which is a positive step toward reducing a modifiable risk factor for PAD.

A. The patient pain reflects the target heart rate has been set too high and needs to be lowered to finish the test. B. The patient’s pain reflects pericarditis and the test should be stopped. C. The patient’s pain reflects ischemia to the myocardium and the test should be stopped. D. The patient’s pain reflects that supplemental oxygen is needed to finish the test.

Correct Answer is C

Explanation

A. The patient pain reflects the target heart rate has been set too high and needs to be lowered to finish the test.

This option suggests that the chest pain is related to the target heart rate being set too high. However, chest pain during an exercise stress test is more commonly associated with myocardial ischemia rather than an inappropriate target heart rate. Lowering the target heart rate may not address the underlying issue of ischemia.

B. The patient’s pain reflects pericarditis and the test should be stopped.

Chest pain during an exercise stress test is more commonly associated with myocardial ischemia rather than pericarditis. Pericarditis is inflammation of the pericardium, and its symptoms may include chest pain that is often sharp and pleuritic. However, during an exercise stress test, the focus is on detecting cardiovascular abnormalities, and chest pain is more concerning for ischemia.

C. The patient’s pain reflects ischemia to the myocardium and the test should be stopped.

This is the most appropriate interpretation. Chest pain during an exercise stress test may indicate insufficient oxygen supply to the myocardium (ischemia). Stopping the test allows for further evaluation and appropriate intervention.

D. The patient’s pain reflects that supplemental oxygen is needed to finish the test.

Chest pain during an exercise stress test is not typically addressed by providing supplemental oxygen. Stopping the test and evaluating the cause of the chest pain is a more appropriate action.

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An admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds. These findings indicated the nurse to monitor the client for what?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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