The nurse provides care for a client diagnosed with bronchitis. Which statement is most significant during the assessment of a client diagnosed with chronic bronchitis?
"I was short of breath when I walked around the block yesterday."
"I have a loose sounding cough every day when I get up in the morning."
"My respiratory secretions are greenish-yellow colored today."
"My feet are swollen and painful at the end of the afternoon."
The Correct Answer is B
Choice A reason: "I was short of breath when I walked around the block yesterday." is not the most significant statement because it is a common symptom of chronic bronchitis, but it does not indicate the severity or the progression of the condition. Shortness of breath is caused by the inflammation and narrowing of the airways, which reduce the airflow and oxygen delivery to the lungs.
Choice B reason: "I have a loose sounding cough every day when I get up in the morning." is the most significant statement because it indicates the presence of excessive mucus production, which is a hallmark of chronic bronchitis. Mucus traps bacteria and other irritants, which can lead to infections and further inflammation of the airways. A chronic cough is defined as a cough that lasts for at least three months in two consecutive years.
Choice C reason: "My respiratory secretions are greenish-yellow colored today." is not the most significant statement because it is a sign of a possible infection, but it does not necessarily indicate chronic bronchitis. Greenish-yellow colored sputum can be caused by various respiratory conditions, such as pneumonia, tuberculosis, or cystic fibrosis.
Choice D reason: "My feet are swollen and painful at the end of the afternoon." is not the most significant statement because it is a sign of a possible complication of chronic bronchitis, but it does not directly relate to the condition. Swollen and painful feet can be caused by right-sided heart failure, which can result from chronic bronchitis. Chronic bronchitis can increase the pressure in the pulmonary arteries, which can strain the right ventricle and cause it to fail. This can lead to fluid retention and edema in the lower extremities.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A sacculated aneurysm in the circle of Willis is not the most likely cause of a left-sided embolic stroke. A sacculated aneurysm is a bulging of a weak spot in the wall of an artery, which may occur in the circle of Willis, a network of arteries at the base of the brain. A sacculated aneurysm may cause a hemorrhagic stroke, which is a bleeding into the brain, not an embolic stroke, which is a blockage of a blood vessel by a clot.
Choice B reason: Rupture of small cerebral blood vessels is not the most likely cause of a left-sided embolic stroke. Rupture of small cerebral blood vessels may occur due to hypertension, diabetes, or aging, which may damage the integrity of the blood vessel walls. Rupture of small cerebral blood vessels may cause a hemorrhagic stroke, which is a bleeding into the brain, not an embolic stroke, which is a blockage of a blood vessel by a clot.
Choice C reason: Diffuse inflammation of the small diameter blood vessels is not the most likely cause of a left-sided embolic stroke. Diffuse inflammation of the small diameter blood vessels may occur due to vasculitis, which is an autoimmune disorder that causes inflammation and narrowing of the blood vessels. Diffuse inflammation of the small diameter blood vessels may cause a thrombotic stroke, which is a formation of a clot within the blood vessel, not an embolic stroke, which is a blockage of a blood vessel by a clot that travels from another site.
Choice D reason: Migration of a clot from the left atrium of the heart is the best explanation for the most likely cause of a left-sided embolic stroke. An embolic stroke is a type of ischemic stroke, which is a lack of blood flow to the brain due to a blockage of a blood vessel by a clot. A clot may form in the left atrium of the heart due to conditions such as atrial fibrillation, which is an irregular heartbeat that causes blood to pool and clot in the heart. A clot may then break off and travel through the bloodstream until it reaches a smaller blood vessel in the brain, where it causes an embolic stroke.
Correct Answer is C
Explanation
Choice A reason: Muscle weakness and motor seizures are not the most serious complication because they are signs of electrolyte imbalance, not urinary tract infection. Electrolyte imbalance is a condition where the levels of minerals and salts in the blood are too high or too low, which can affect the nerve and muscle function, causing symptoms such as weakness, spasms, or seizures. Electrolyte imbalance can be caused by various factors, such as dehydration, kidney failure, or medications.
Choice B reason: Upper abdominal pain and cramping are not the most serious complication because they are signs of gastritis, not urinary tract infection. Gastritis is a condition where the lining of the stomach is inflamed, causing symptoms such as pain, nausea, or vomiting. Gastritis can be caused by various factors, such as infections, stress, or medications.
Choice C reason: Confusion and agitation are the most serious complication because they are signs of sepsis, which is a life-threatening condition where the body's response to an infection causes widespread inflammation and organ damage. Sepsis can be caused by various types of infections, including urinary tract infection, which is an infection that affects the bladder, urethra, or kidneys. Sepsis can cause symptoms such as confusion, agitation, fever, chills, or shock.
Choice D reason: Periorbital edema and cardiac dysrhythmias are not the most serious complication because they are signs of heart failure, not urinary tract infection. Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs, causing symptoms such as swelling, shortness of breath, or irregular heartbeat. Heart failure can be caused by various factors, such as coronary artery disease, hypertension, or diabetes.
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