Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

Asthma related to environmental factors

COPD related to smoking

Pneumonia related to bacterial infection

Tuberculosis related to Mycobacterium tuberculosis

Answer and Explanation

The Correct Answer is A

Choice A rationale

The patient’s history of asthma, previous hospitalizations for asthma-related symptoms, and the current presentation of difficulty breathing and wheezing suggest that she is likely experiencing an asthma exacerbation related to environmental factors. Asthma is a chronic condition that can cause symptoms such as wheezing, shortness of breath, and chest tightness, which the patient is currently experiencing. Environmental factors such as allergens, air pollution, and changes in weather can trigger asthma symptoms.

Choice B rationale

While smoking is a major risk factor for COPD, the patient denies smoking. Additionally, COPD is more common in older adults, and the patient is only 22 years old. Therefore, it is less likely that her symptoms are due to COPD.

Choice C rationale

Pneumonia is typically associated with additional symptoms such as fever, cough with phlegm, and chest pain. The patient’s symptoms do not align with a typical presentation of pneumonia.

Choice D rationale

Tuberculosis is a bacterial infection that typically presents with a chronic cough, weight loss, and night sweats. The patient’s symptoms do not align with a typical presentation of tuberculosis.

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Correct Answer is A

Explanation

Choice A rationale

The right foot being cool to the touch and appearing pale and blanched is a classic sign of arterial obstruction. After a cardiac catheterization via the right femoral artery, it’s possible that a clot or other obstruction could have formed, impeding blood flow to the right foot. This would cause the foot to become cool and pale due to lack of warm, oxygenated blood.

Choice B rationale

While a moist and oozing pressure dressing at the right femoral area could indicate a problem such as bleeding from the catheter insertion site, it does not specifically indicate arterial obstruction.

Choice C rationale

A downward trend in blood pressure and a rapid, irregular pulse could indicate many different problems, including shock, heart failure, or arrhythmias. However, these symptoms are not specific to arterial obstruction.

Choice D rationale

A weaker pulse distal to the femoral artery on the left foot compared to the right foot could indicate a problem with circulation to the left foot, but it does not indicate an obstruction in the right femoral artery.

A. Thick, dry, and dark area on bilateral heels. B. Broken skin without evidence of undermining. C. Defined area of persistent redness over bone. D. Superficial sacral pressure injury with defined margins.

Correct Answer is C

Explanation

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

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Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

Correct Answer is A

Explanation

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?

The nurse is conducting a functional assessment on an older patient who has lost five pounds (2.27 Kg) since the last visit 12 weeks ago and reports a decrease in energy and appetite.Which action should the nurse include during the assessment?

An elderly patient who had a fall at a store is admitted with a potential right hip fracture.What assessment finding should the nurse report to the healthcare provider?

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

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After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased.The family wishes to see the body before it is taken to the funeral home.Which interventions should the nurse take to prepare the body before the family enters the room? Select all that apply.

While changing a postoperative patient’s dressing, the nurse notices purulent drainage at the site.Before reporting this to the healthcare provider, which of the patient’s lab values should the nurse check?