The patient with emphysema comes to the emergency department with difficulty breathing. What finding should the nurse anticipate during data collection? Select all that apply
diminished breath sounds
ruddy skin color
use of accessory muscles
excess mucus production
barrel shaped chest
Correct Answer : A,C,E
A. Diminished breath sounds can occur in emphysema due to decreased air movement through damaged and enlarged air sacs (alveoli). The destruction of alveolar walls reduces the surface area available for gas exchange and can result in decreased breath sounds.
C. Patients with emphysema may use accessory muscles, such as neck and shoulder muscles, to assist with breathing during periods of respiratory distress. These muscles are recruited to help increase the size of the thoracic cavity and improve airflow.
E. A barrel-shaped chest is a common physical finding in patients with emphysema. It results from hyperinflation of the lungs and is characterized by an increased anterior-posterior diameter of the chest. This change in chest shape is due to air trapping in the lungs, leading to overinflation of the alveoli and increased residual volume.
B. Ruddy skin color, which refers to a reddish or flushed complexion, is not typically associated with emphysema. Instead, patients with emphysema may exhibit cyanosis (bluish discoloration of the skin) during periods of hypoxemia (low oxygen levels).
D. Excess mucus production (mucus hypersecretion) is a characteristic feature of chronic bronchitis, which is often present alongside emphysema in chronic obstructive pulmonary disease (COPD) but it is not typically a primary feature of emphysema itself.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. The primary cause of peptic ulcer disease is infection with Helicobacter pylori (H. pylori) bacteria. H. pylori infection is associated with the majority of peptic ulcers, particularly those in the stomach. This bacterium weakens the protective mucous lining of the stomach and duodenum, allowing stomach acid to damage the underlying tissue and form ulcers.
A. Spicy foods can exacerbate symptoms in some individuals with peptic ulcer disease but they are not a primary cause of the condition. Spicy foods can irritate the lining of the stomach or duodenum, potentially worsening symptoms, but they do not directly cause ulcers.
B. Stress was once thought to be a major factor in the development of peptic ulcers, but research has shown that while stress may aggravate symptoms, it is not a primary cause of peptic ulcer disease.
C. Excessive caffeine intake was also previously believed to be a major cause of peptic ulcer disease, but this is not entirely accurate. While caffeine can stimulate gastric acid secretion, leading to increased acidity in the stomach, it is not a primary cause of peptic ulcers.
Correct Answer is D
Explanation
D. Patients who have had a stroke are at high risk for aspiration pneumonia due to potential impairment of their swallowing mechanisms and decreased gag reflex, which can occur if the stroke affects the parts of the brain that control these functions. Dysphagia is a common complication of strokes and significantly increases the risk of aspiration.
A. Migraines can cause significant discomfort and sometimes nausea and vomiting, they do not typically impair swallowing or protective airway reflexes. Thus, this patient is not at high risk for aspiration pneumonia.
B. Leukemia itself does not directly increase the risk of aspiration pneumonia. However, if the patient has complications such as severe weakness, altered mental status, or treatment side effects (like mucositis or infections), their risk could be increased, but it is not the primary concern in most leukemia cases.
C. Asthma affects the airways and causes difficulty breathing but does not typically impair swallowing or increase the risk of aspiration. While severe asthma attacks can cause coughing and choking, the primary issue is airway inflammation, not the risk of inhaling food or liquid.
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