Which of the following assessment findings should the nurse report to the practitioner? (Select all that apply)
Use of accessory muscles
Nail bed greater than 160 degrees
Circumoral cyanosis
Pursed lip breathing
Anteroposterior-to-transverse diameter of 1:1
Correct Answer : A,B,C,D,E
A. Use of accessory muscles
Explanation: Using accessory muscles during breathing indicates increased effort to breathe, which can be a sign of respiratory distress. It suggests that the client is having difficulty breathing and is using additional muscles to aid in the process. This finding should be reported to the practitioner for further evaluation.
B. Nail bed greater than 160 degrees
Explanation: A nail bed angle greater than 160 degrees, also known as clubbing, is an abnormal finding and can be associated with chronic respiratory or cardiovascular conditions. It may indicate insufficient oxygenation and should be reported to the practitioner for evaluation.
C. Circumoral cyanosis
Explanation: Circumoral cyanosis, which is a bluish discoloration around the mouth, indicates inadequate oxygenation. It can be a sign of respiratory or cardiac problems and should be reported to the practitioner for further assessment and intervention.
D. Pursed lip breathing
Explanation: Pursed lip breathing is a technique often used by individuals with respiratory difficulties to improve oxygen exchange. However, if it's observed in a person who does not normally use this technique, it could indicate respiratory distress and should be reported to the practitioner for evaluation.
E. Anteroposterior-to-transverse diameter of 1:1
Explanation: An anteroposterior-to-transverse diameter of 1:1 (also known as barrel chest) is an abnormal finding often associated with chronic obstructive pulmonary disease (COPD). It suggests overinflation of the lungs and can impair effective breathing. This finding should be reported to the practitioner for further evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In this sequence:
Vena cava brings deoxygenated blood from the body into the right atrium.
Blood flows from the right atrium to the right ventricle through the tricuspid valve.
The right ventricle pumps blood into the pulmonary artery to the lungs.
In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.
From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.
The left ventricle then pumps oxygenated blood into the body through the aorta.
This sequence represents the systemic and pulmonary circulation of the heart.
Correct Answer is C
Explanation
A. VI
Cranial Nerve VI is the Abducent Nerve, which controls the movement of the lateral rectus muscle, allowing the eye to move laterally (abduct). Dysfunction of this nerve can cause difficulty in moving the eye outward.
B. V
Cranial Nerve V is the Trigeminal Nerve. It has both sensory and motor functions. Sensory functions include providing sensation to the face, sinuses, and teeth. Motor functions include controlling the muscles used for chewing (mastication).
C. II
Cranial Nerve II is the Optic Nerve. It is purely a sensory nerve responsible for vision. The optic nerve carries visual information from the retina of the eye to the brain.
D. III
Cranial Nerve III is the Oculomotor Nerve. It is primarily a motor nerve but also has some autonomic functions. It controls most of the eye movements (except lateral movement controlled by VI) and regulates the size of the pupil and the shape of the lens in the eye for focusing.
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