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 A rationale:
Colloidal oatmeal-based lotion: While colloidal oatmeal can soothe and moisturize dry, itchy skin, it does not have the anti- inflammatory properties necessary to effectively treat the underlying inflammation of psoriasis.
It may provide temporary relief of symptoms, but it won't address the root cause of the condition.
Choice B rationale:
Topical corticosteroids: These medications are the mainstay of treatment for psoriasis. They work by reducing inflammation and slowing the growth of skin cells.
Topical corticosteroids come in a variety of strengths and formulations, including creams, ointments, gels, lotions, and sprays. The choice of formulation will depend on the severity of the psoriasis, the location of the lesions, and the patient's preferences. Choice C rationale:
Topical analgesics: Topical analgesics, such as lidocaine or benzocaine, can help to relieve pain and itching associated with psoriasis.
However, they do not address the underlying inflammation and are not a long-term solution for managing the condition. They are typically used as adjunctive therapy, in conjunction with other psoriasis treatments.
Choice D rationale:
Topical antifungals: Topical antifungal medications are used to treat fungal infections, such as ringworm and athlete's foot. They are not effective in treating psoriasis, which is an autoimmune condition, not a fungal infection.
Correct Answer is B
Explanation
Choice A rationale:
Total protein is a measure of the overall protein content in the blood. It includes albumin and globulin.
While it can be helpful in assessing nutritional status and liver function, it is not directly relevant to the client's current symptoms of pallor and fatigue.
Decreased total protein can indicate malnutrition or liver disease, but these conditions would not typically cause the specific symptoms of pallor and fatigue.
Therefore, total protein is not the most important laboratory value to review in this case.
Choice B rationale:
Hemoglobin is the protein in red blood cells that carries oxygen throughout the body.
Paleness (pallor) is a common sign of anemia, which is a condition characterized by a low hemoglobin level. Fatigue is also a common symptom of anemia, as the body's tissues are not receiving enough oxygen.
Diclofenac, a non-steroidal anti-inflammatory drug (NSAID), can cause gastrointestinal bleeding, which can lead to anemia. Therefore, it is essential for the nurse to review the client's hemoglobin level to assess for potential anemia.
Choice C rationale:
Glucose is a type of sugar that the body uses for energy.
Abnormal glucose levels can cause various symptoms, including fatigue. However, glucose levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for diabetes or other disorders that affect glucose metabolism.
Therefore, glucose is not the most likely cause of the client's symptoms.
Choice D rationale:
Sodium is an electrolyte that helps regulate fluid balance in the body.
Abnormal sodium levels can cause various symptoms, including fatigue and weakness. However, sodium levels would not typically cause pallor.
Additionally, there is no indication in the question stem that the client has any risk factors for electrolyte imbalances. Therefore, sodium is not the most likely cause of the client's symptoms.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today