The client is a 51-year-old male with pneumonia.
The client has a history of hypertension and takes enalapril and a multivitamin daily.
His surgical history includes adenoid removal at age 4-years and a surgical repair of a fractured tibia at age 20. According to the client’s vital signs, he is experiencing which condition?

Hypothermia.

Tachypnea.

Hypotension.

Hypertension.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)

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Correct Answer is D

Explanation

Rationale for Choice A: Dysrhythmia

There is no information in the question stem to suggest that the patient is experiencing a dysrhythmia.

Dysrhythmias are abnormal heart rhythms that can be caused by a variety of factors, including heart disease, electrolyte imbalances, and medications.

While it is possible that the patient could develop a dysrhythmia as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, enalapril, which the patient is taking for hypertension, is not typically associated with an increased risk of dysrhythmias.

Rationale for Choice B: Toxicity

There is no information in the question stem to suggest that the patient is experiencing toxicity.

Toxicity can be caused by a variety of substances, including medications, drugs, and environmental toxins.

While it is possible that the patient could develop toxicity as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, the patient's medication regimen of enalapril and a multivitamin is not typically associated with an increased risk of toxicity.

Rationale for Choice C: Anemia

There is no information in the question stem to suggest that the patient is anemic.

Anemia is a condition in which there is a decreased number of red blood cells or hemoglobin in the blood.

While it is possible that the patient could develop anemia as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, the patient's surgical history of adenoid removal and a fractured tibia is not typically associated with an increased risk of anemia.

Rationale for Choice D: Pneumonia

The patient is a 51-year-old male with a diagnosis of pneumonia.

Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi.

The patient's symptoms, such as cough, fever, and difficulty breathing, are all consistent with a diagnosis of pneumonia.

Additionally, the patient's medical history of hypertension does not rule out pneumonia, and in fact, some studies have shown that hypertension may be a risk factor for developing pneumonia.

Therefore, pneumonia is the most likely condition that the patient has based on the information provided.

A. Wild rice. B. Oatmeal. C. Corn chips. D. Potatoes.

Correct Answer is B

Explanation

Choice A rationale:

Wild rice is naturally gluten-free. It is not a grain, but rather a semi-aquatic grass seed. It is safe for individuals with celiac disease to consume.

Wild rice is a good source of nutrients. It is high in fiber, protein, and antioxidants, and it contains a variety of vitamins and minerals, including manganese, phosphorus, magnesium, and zinc. These nutrients can help to support overall health and well-being.

Wild rice can be a versatile ingredient in many dishes. It can be used in salads, soups, stews, pilafs, and even desserts.

Choice B rationale:

Oatmeal is not gluten-free. It is made from oats, which are a type of cereal grain that contains gluten. Individuals with celiac disease must avoid gluten, as it can trigger an autoimmune reaction that damages the small intestine.

Even small amounts of gluten can cause harm. Consuming even a small amount of oatmeal can cause symptoms such as abdominal pain, bloating, diarrhea, fatigue, and headache in individuals with celiac disease.

Long-term damage can occur. If individuals with celiac disease continue to consume gluten, it can lead to long-term health problems, such as malnutrition, osteoporosis, and infertility.

Choice C rationale:

Corn chips are typically gluten-free. However, it is important to check the label to be sure, as some brands may contain gluten- containing ingredients, such as wheat flour or barley malt.

Reading labels is essential. Individuals with celiac disease should always read food labels carefully to ensure that products are gluten-free.

Choice D rationale:

Potatoes are naturally gluten-free. They are a safe and healthy food choice for individuals with celiac disease.

Potatoes are a versatile and nutritious food. They are a good source of carbohydrates, fiber, potassium, vitamin C, and other nutrients.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is discussing dietary choices with a client who is newly diagnosed with celiac disease. Which menu choice by the client indicates a need for further teaching?

Correct Answer is B

Explanation

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