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

The correct answer is choice D. Reported history of alcoholism.

Choice A rationale:

Employment as a construction worker is not directly relevant to the administration of terbinafine HCL. While it may affect the client’s overall health and risk of injury, it does not impact the medication’s safety or efficacy.

Choice B rationale:

A white blood cell count of 8,500/mm³ (8.5 x 10³/L) is within the normal range and does not indicate any immediate concern that would affect the administration of terbinafine HCL.

Choice C rationale:

Thick and yellow toenails are typical symptoms of a fungal toenail infection and are the reason for prescribing terbinafine HCL. This finding confirms the diagnosis but does not present a contraindication to the medication.

Choice D rationale:

A reported history of alcoholism is crucial to address because terbinafine HCL can cause liver toxicity. Clients with a history of alcoholism are at higher risk for liver damage, and this must be carefully evaluated before starting the medication.

A. Dysrhythmia B. Toxicity C. Anemia D. Pneumonia

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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