When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

There is a history of COPD.

The client has a collapsed lung

The client's lungs are functioning normally.

A chronic lung infection is the likely condition.

Answer and Explanation

The Correct Answer is B

A. Chronic Obstructive Pulmonary Disease (COPD) can lead to decreased lung function and abnormalities in lung expansion. However, COPD typically results in a more generalized decrease in lung expansion and breath sounds, rather than pronounced unilateral inequality. While COPD can cause irregularities in lung expansion, it is less likely to cause significant unilateral differences in lung expansion.
B. Unequal lung expansion is a key sign of a collapsed lung, or pneumothorax. When a lung collapses, the affected side will show reduced or absent expansion compared to the unaffected side. This is because the collapsed lung cannot expand properly during inhalation, leading to noticeable differences in breath sounds and lung movement on physical examination.
C. If the client's lungs were functioning normally, one would expect to observe symmetrical lung expansion. Unequal lung expansion is not a normal finding and usually indicates some form of pathology or abnormality in the lung or thoracic cavity. Normal lung function should result in even expansion of both lungs.
D. Chronic lung infections, such as tuberculosis or severe pneumonia, might cause abnormalities in lung sounds or localized lung issues, but they are less likely to cause pronounced unilateral differences in lung expansion. While they can affect lung function, they typically do not cause the same degree of unilateral expansion issues as a pneumothorax would.

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Correct Answer is D

Explanation

A. While a 24-hour diet history can provide valuable information about a person's dietary intake, it may not accurately reflect their long-term nutritional habits. Additionally, some individuals may underreport or overreport their food intake.
B. A person's current appetite can be affected by various factors, including illness, medication, and emotional state. It may not be a reliable indicator of long-term nutritional status.
C. While weight loss can be a sign of nutritional problems, it is not always indicative of a deficiency. Other factors, such as increased physical activity or illness, can also contribute to weight loss.
D. The condition of hair, nails, and skin can provide valuable clues about a person's nutritional status.
For example, dry, brittle hair and nails, as well as pale or scaly skin, can be signs of nutrient deficiencies such as iron, vitamin B12, or protein deficiency. These visible signs can be more indicative of long-term nutritional deficiencies than other factors.

A. Dyspnea. B. Peripheral edema. C. Intercostal retractions. D. Headaches. E. Jugular venous distension.

Correct Answer is ["A","B","E"]

Explanation

A. Dyspnea, or shortness of breath, is a common symptom of heart failure exacerbation. It occurs because the heart is unable to effectively pump blood, leading to pulmonary congestion and fluid accumulation in the lungs. This symptom is significant in confirming an exacerbation of heart failure.
B. Peripheral edema, or swelling of the legs and ankles, is another common sign of heart failure exacerbation. It results from fluid buildup due to the heart's decreased ability to manage blood volume effectively. This finding is indicative of fluid retention and can confirm an exacerbation of heart failure.
C. Intercostal retractions are typically seen in respiratory distress, especially in conditions affecting the lungs or severe respiratory conditions. While they can occur with severe pulmonary congestion in heart failure, they are more directly associated with respiratory issues rather than specifically confirming heart failure exacerbation.
D. Headaches are not a typical or primary symptom of heart failure exacerbation. They can be associated with various conditions but are not specific to heart failure. This symptom is less relevant in confirming an exacerbation of heart failure.
E. Jugular venous distension is a classic sign of right-sided heart failure or fluid overload. It occurs when there is increased pressure in the venous system due to the heart's inability to handle blood volume effectively.

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When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

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Naxlex Comprehensive Predictor Exams

The nurse is conducting a physical assessment of a young adult. Which information provides the best indication of the individual's nutritional status?

Correct Answer is D

Explanation

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HP? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

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