The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

Pneumonia

Chronic emphysema

Pneumothorax

Congestive heart failure

Answer and Explanation

The Correct Answer is B

A. Pneumonia typically presents with fever, productive cough, and crackles rather than wheezing and tripod positioning.
B. Chronic emphysema is correct. The tripod position (leaning forward, hands on knees) is a classic sign of severe obstructive lung disease, such as emphysema or COPD. Wheezing and dyspnea at rest suggest air trapping and difficulty exhaling, which are hallmarks of this condition. The oxygen saturation of 91% is common in COPD patients due to chronic hypoxemia.
C. Pneumothorax presents with sudden onset chest pain, absent breath sounds on one side, and tracheal deviation (if severe) rather than wheezing.
D. Congestive heart failure can cause dyspnea but typically presents with crackles due to pulmonary edema rather than wheezing and tripod positioning.

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Correct Answer is D

Explanation

A. Thinning of the vertebral discs leads to a decrease in height, not weight.
B. Lean body mass actually decreases with aging, contributing to weight loss rather than gain.
C. Spinal kyphosis affects posture but does not significantly contribute to changes in body weight.
D. Loss of muscle tissue (sarcopenia) is correct because aging leads to a decline in muscle mass, which contributes to weight loss. Additionally, a slower metabolism and reduced physical activity further affect body composition.

A. "The documentation satisfies legal standards established by health care organizations and institutions." B. "Documentation of the initial assessment becomes the foundation for the entire nursing process." C. "Incorrect conclusions may be made without the documentation of the nurse's opinions." D. "Health care institutions have established policies regarding documentation of initial assessments."

Correct Answer is B

Explanation

A. While documentation does satisfy legal standards, the primary reason for documenting the initial assessment is to guide the entire nursing process.
B. "Documentation of the initial assessment becomes the foundation for the entire nursing process" is correct because all subsequent care planning, interventions, and evaluations depend on accurate initial assessment data.
C. Documentation should be objective, not based on the nurse’s opinions.
D. Institutional policies are important, but the significance of initial assessment documentation lies in its role in guiding patient care.

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The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After teaching a group of students about changes in body weight due to aging, the instructor determines that the students have understood the teaching when they state which of the following?

Correct Answer is D

Explanation

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

Correct Answer is B

Explanation

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

What is the primary purpose of a nursing health assessment?

The nurse has completed the comprehensive health assessment of a client who has been admitted for the treatment of community-acquired pneumonia. Following the completion of this assessment, why does the nurse periodically perform a partial assessment of the client?

An older adult client has presented to the emergency department with signs and symptoms of dehydration. When assessing the client for risk factors that may have contributed to this condition, what question should the nurse prioritize?

A nursing student correctly describes a risk diagnosis by which of the following statements?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?