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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Monitoring blood sugar levels regularly, as recommended by the doctor, is crucial for managing type 2 diabetes effectively. It helps patients track their glucose levels, identify patterns, and make informed decisions about medication, diet, and lifestyle choices to maintain optimal blood sugar control.
A. Drinking orange juice to treat high blood sugar is not recommended because it can cause a rapid increase in blood sugar levels due to its high sugar content. Instead, patients should focus on consuming foods or beverages with lower glycemic index values and more stable glucose responses.
B. Regular physical activity is an essential component of diabetes management as it helps improve insulin sensitivity, lower blood sugar levels, control weight, and reduce the risk of complications. Patients with diabetes are encouraged to engage in regular exercise as part of their overall treatment plan.
D. Eating a diet high in carbohydrates can lead to spikes in blood sugar levels, which can be detrimental for individuals with type 2 diabetes. Instead, patients are encouraged to follow a balanced diet that includes a variety of nutrient-rich foods, with a focus on whole grains, lean proteins, healthy fats, fruits, and vegetables, while moderating carbohydrate intake.
Correct Answer is A
Explanation
A. Sucralfate works by forming a protective barrier over the ulcer site. It adheres to the ulcer, shielding it from the harmful effects of gastric acid, pepsin, and bile salts. This protection allows the ulcer to heal by preventing further irritation and damage.
B. Medications that prevent gastric acid secretion are typically proton pump inhibitors (PPIs) or H2 receptor antagonists. Sucralfate does not reduce or inhibit the production of gastric acid; instead, it protects the ulcer from the acid already present.
C. Antacids are the type of medication that neutralize gastric acid. Sucralfate does not neutralize acid; it acts locally at the ulcer site to create a protective coating.
D. Antibiotics are used to kill Helicobacter pylori, the bacteria often responsible for causing peptic ulcers. Sucralfate does not have antibacterial properties and does not target or eliminate bacteria.
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