An older patient is admitted for bacterial pneumonia. The only abnormal assessment values include a heart rate of 102 beats per minute, slight cyanosis of the nail beds, and mild confusion. The patients daughter questions the possibility of pneumonia stating, He isn’t coughing or having any difficulty breathing. The nurse responds most appropriately by saying.
"Older adults frequently lack the typical signs of a respiratory infection."
"Respiratory problems develop only after the infection is well established."
"People your dad's age often lack the muscular strength to cough."
"We are lucky to determine the problem in its early stage."
The Correct Answer is A
A. Older adults often present with atypical symptoms when they have respiratory infections, such as pneumonia. They may not always exhibit classic signs like a cough or significant difficulty breathing. Instead, symptoms might include confusion, changes in mental status, or subtle signs of respiratory distress. This explanation addresses the patient's daughter's concern by acknowledging that older adults can show different manifestations of illness compared to younger people.
B.A This response is misleading. Respiratory problems can develop at any stage of an infection, not only after the infection is well established. Pneumonia can sometimes present without obvious respiratory distress or symptoms, especially in older adults. It’s crucial to recognize that pneumonia can manifest in various ways and early intervention is important.
C. While it's true that older adults may experience decreased muscular strength, this response might be too specific and not fully address the broader issue. It's also possible that the patient has enough strength but is not showing the typical signs of infection. This response might oversimplify the situation and could be seen as dismissive of the patient's actual symptoms.
D. This response, while optimistic, is not entirely appropriate in this context. It might come off as minimizing the daughter's concerns and does not directly address why the patient might not exhibit typical symptoms of pneumonia. It’s important to acknowledge the atypical presentation rather than simply focusing on the timing of the diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Reflex tone refers to the neurological response of the body to stimuli and is not directly related to the action or monitoring of anticoagulant therapy. While assessing reflexes might be important for overall patient health, it is not specifically relevant to monitoring the effects of warfarin. Reflex tone does not provide information on the anticoagulation status or risk of bleeding associated with warfarin therapy.
B. Checking the body for bruising helps assess the safety of warfarin therapy and may indicate the need for dosage adjustments or further investigation if bruising is excessive. However, while monitoring for bruising is essential, it is not the primary method for assessing the effectiveness and safety of anticoagulant therapy.
C. While monitoring kidney function is relevant for overall medication management, it is not the primary focus for directly assessing the effectiveness or safety of warfarin therapy. Kidney function is more related to adjusting doses and avoiding potential complications.
D. Regularly reviewing PT is crucial for managing warfarin therapy because it directly reflects the anticoagulation effect of the medication. The International Normalized Ratio (INR), derived from PT, is used to ensure the patient is within the therapeutic range for effective anticoagulation while minimizing the risk of bleeding.
Correct Answer is B
Explanation
A. Serum complement levels are used to evaluate the complement system, which is part of the immune system and plays a role in inflammation and infection. While complement levels can be important in certain inflammatory and autoimmune conditions, they are not typically used to assess age-related changes that impact drug metabolism or the appropriate selection of pain medications.
B. The Glomerular Filtration Rate (GFR) is a key measure of kidney function. In older adults, kidney function often declines with age, affecting the metabolism and excretion of medications. Many drugs are primarily eliminated through the kidneys, and impaired kidney function can lead to drug accumulation, increased risk of toxicity, and altered therapeutic efficacy. Assessing GFR helps in adjusting medication doses to avoid adverse effects and ensure safe and effective treatment.
C. A White Blood Count (WBC) measures the number of white blood cells in the blood and is used to assess the body's response to infection, inflammation, and other conditions. While it provides valuable information about immune function and potential infections, it does not directly address age-related changes in drug metabolism or pharmacokinetics. Therefore, it is not the primary test for evaluating how aging might affect drug therapy.
D. An Electroencephalogram (EEG) records the electrical activity of the brain and is used to diagnose neurological conditions such as seizures, sleep disorders, and brain abnormalities. Although EEGs are valuable in certain neurological assessments, they do not provide information on how age-related physiological changes affect drug metabolism or how to tailor drug regimens for older adults.
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