Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

barrel chest

respiratory rate of 22 per minute

Oral cyanosis

decreased lung sounds on expiration

Pursed-lip expiration

Answer and Explanation

The Correct Answer is C

A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.

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Correct Answer is A

Explanation

A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.

A. venous insufficiency B. claudication C. muscle cramps D. deep vein thrombosis E. bruit from turbulent blood flow

Correct Answer is B

Explanation

A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.

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Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

Correct Answer is A

Explanation

A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

Correct Answer is B

Explanation

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