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.
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)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Isoniazid's Mechanism of Action:
It targets and inhibits the synthesis of mycolic acids, which are essential components of the cell wall of Mycobacterium tuberculosis, the bacteria that cause tuberculosis.
By disrupting cell wall formation, isoniazid prevents bacterial growth and multiplication, leading to the suppression and eventual eradication of the infection.
Clinical Manifestations of Active TB:
Persistent cough, often productive of sputum (phlegm), is a hallmark symptom of TB. The sputum may contain blood or have a rusty-colored appearance.
Other common symptoms include fever, night sweats, fatigue, weight loss, and chest pain. How Isoniazid Reduces Cough and Sputum:
As isoniazid effectively kills the TB bacteria, the inflammatory process within the lungs subsides.
This leads to a gradual decrease in the production of sputum, which is a direct result of the inflammatory response. Consequently, the frequency and severity of coughing episodes also diminish.
Monitoring Treatment Response:
Regular sputum smears and cultures are essential to assess the response to treatment.
A positive sputum smear indicates the presence of live TB bacteria, while a positive culture confirms their growth in the laboratory.
A gradual decrease in the number of bacteria seen on sputum smears, followed by negative cultures, signals a favorable response to treatment.
Timeframe for Improvement:
It's important to note that clinical improvement, including a reduction in cough and sputum, may not be immediately evident. It typically takes several weeks of consistent isoniazid therapy to achieve noticeable results.
Therefore, adherence to the prescribed treatment regimen is crucial for successful TB eradication. Addressing Other Choices:
Choice A: Decreased appetite and weight loss are often associated with active TB due to systemic inflammation and nutritional deficiencies. While isoniazid treatment may indirectly improve appetite and weight gain over time, these are not primary indicators of its effectiveness in suppressing the TB infection itself.
Choice C: Vertigo and tinnitus are potential side effects of isoniazid, but they do not reflect its efficacy in treating TB.
Choice D: A positive sputum smear and culture would indicate ongoing TB infection and a lack of response to treatment.
Correct Answer is C
Explanation
Choice A rationale:
Carbon dioxide is primarily eliminated through the lungs, not the kidneys. While the kidneys do play a role in acid-base balance, their primary mechanism for regulating pH is through the excretion or retention of bicarbonate ions (HCO3-), not carbon dioxide itself.
The kidneys' ability to compensate for respiratory acidosis is limited. In cases of severe respiratory acidosis, the kidneys may not be able to adequately compensate, leading to a further decrease in blood pH.
Choice B rationale:
Hyperventilation would actually decrease carbon dioxide levels in the blood, not increase them. Hyperventilation is a state of rapid, deep breathing that leads to increased exhalation of carbon dioxide. This can result in respiratory alkalosis, which is the opposite of respiratory acidosis.
Choice D rationale:
Low blood oxygen levels (hypoxia) can stimulate respiration, but this would not directly cause respiratory acidosis. In fact, hypoxia can sometimes lead to respiratory alkalosis due to hyperventilation.
Respiratory acidosis is primarily caused by impaired carbon dioxide elimination, not decreased oxygen levels.
Choice C rationale:
High levels of carbon dioxide in the blood (hypercapnia) are the hallmark feature of respiratory acidosis. This can occur due to a variety of factors that impair ventilation, such as:
Chronic obstructive pulmonary disease (COPD) Asthma
Pneumonia Sleep apnea
Neuromuscular disorders that affect breathing Drug overdose (e.g., opioids)
The accumulation of carbon dioxide in the blood leads to a decrease in blood pH, which can have a range of negative effects on the body's organ systems.
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