The nurse is assessing a patient who is diagnosed with tuberculosis. Which assessment finding correlates with this diagnosis?
Rhonchi
weight gain
Hemoptysis
Frothy sputum
The Correct Answer is C
A. Rhonchi are abnormal lung sounds that result from obstruction or secretions in larger airways. They are more commonly associated with conditions like chronic bronchitis or COPD rather than tuberculosis. While TB can lead to various lung sounds, rhonchi are not a hallmark of the disease.
B. Weight gain is generally not associated with tuberculosis. In fact, TB often leads to weight loss due to factors like loss of appetite, increased metabolic demand, and systemic effects of the infection. Patients with active TB frequently present with cachexia (wasting) or weight loss, not weight gain.
C. Hemoptysis, or coughing up blood, is a significant and classic symptom associated with tuberculosis, especially in cases involving pulmonary TB. It occurs due to the erosion of blood vessels in the lungs as the disease progresses. This makes it a strong correlating finding with a diagnosis of tuberculosis.
D. Frothy sputum is more characteristic of pulmonary edema or conditions such as congestive heart failure. In tuberculosis, sputum may be mucoid or purulent and sometimes contains blood, but it is not typically described as frothy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While this information is important for understanding the cause of the asthma exacerbation, it is not the most critical piece of information needed for immediate treatment.
B. Knowing when the symptoms began can help determine the severity of the exacerbation and the need for additional interventions. However, it is not as important as knowing the last dose of medication.
C. This information is crucial for determining the appropriate treatment. If the child has not received their regular medications as prescribed, they may need additional doses to manage the exacerbation.
D. Knowing the child's history of asthma exacerbations is important for assessing the severity of the current episode and planning long-term management. However, it is not the most critical piece of information needed for immediate treatment.
Correct Answer is C
Explanation
A. Mouth breathing is common after a tonsillectomy due to postoperative swelling and discomfort. It is not specifically a sign of hemorrhage. Instead, it is a typical adjustment as the child copes with throat pain and may find it easier to breathe through the mouth.
B. While reports of pain are expected after a tonsillectomy due to the nature of the surgery, they are not indicative of hemorrhage. Pain management is an important part of postoperative care, but increased pain alone does not signal bleeding.
C. Frequent swallowing can be a significant manifestation of hemorrhage following a tonsillectomy. This behavior may indicate that the child is trying to clear blood or secretions from the throat, or it may suggest that the child is swallowing blood that is pooling in the throat. It is an important sign for the nurse to monitor, as it can indicate active bleeding.
D. Reports of thirst are common after surgery due to fasting before the procedure and the dry mouth that can result from mouth breathing or the surgical site itself. While excessive thirst should be addressed, it is not a direct indicator of hemorrhage.
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