Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

Clubbing of the fingernails

Tracheal deviation

Contraction of the diaphragm

Auscultation of rhonchi throughout the lungs

Answer and Explanation

The Correct Answer is B

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

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Correct Answer is A

Explanation

A. Elevate the head of the client's bed to 45° during meals: This is the correct action. Elevating the head during meals helps promote proper swallowing and reduces the risk of aspiration by preventing food or liquid from entering the airway. A semi-upright position is essential for clients at risk of aspiration, particularly those with dementia, who may have impaired swallowing reflexes.
B. Provide the client with oral hygiene: While important for oral health and to reduce bacteria in the mouth, this action does not directly reduce the risk of aspiration during meals. Oral hygiene is beneficial for preventing infections, but it doesn't influence the act of swallowing during eating.
C. Instruct the client to tilt their head back while swallowing: This is incorrect. Tilting the head back can cause difficulty in swallowing and increase the risk of aspiration. The correct technique is to maintain a neutral or slightly forward position of the head to allow food to travel smoothly down the esophagus and prevent it from entering the airway.
D. Turn on the television for the client during meals: This is not recommended as it can distract the client from focusing on eating. Distractions like a television may reduce the client's ability to concentrate on the swallowing process, increasing the risk of aspiration and choking.

A. Moon face B. Enlarged distal extremities C. Hepatomegaly D. Coarse facial features E. Loss of color discrimination

Correct Answer is ["B","C","D"]

Explanation

A. Moon face is typically associated with Cushing's syndrome, not acromegaly, which is characterized by changes in the hands, feet, and facial features rather than a rounded, moon-shaped face.
B. Enlarged distal extremities (hands and feet) are classic symptoms of acromegaly due to excessive growth hormone production.
C. Hepatomegaly (enlarged liver) is a common finding in acromegaly due to the overproduction of growth hormone, which affects organ size.
D. Coarse facial features (such as a protruding jaw, enlarged nose, and thickened lips) are a hallmark of acromegaly, resulting from the overgrowth of soft tissues.
E. Loss of color discrimination is not typically associated with acromegaly and may be seen in other conditions affecting the optic nerve or eye, but it is not a key symptom of acromegaly.

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Which of the following assessment findings indicates an emergency and the need for immediate action on the part of the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has dementia. Which of the following actions should the nurse take to reduce the client's risk of aspiration pneumonia?

Correct Answer is A

Explanation

A nurse is caring for a client who is being evaluated for acromegaly. Which of the following manifestations should the nurse expect to find during assessment? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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