Which sign or symptom would the nurse anticipate in a patient diagnosed with tuberculosis? Select all that apply. One, some, or all responses may be correct.
Weight gain
Low-grade fever
Dyspnea
Contusion
Lethargy
Night sweats
Correct Answer : B,C,E,F
Choice A Reason:
Weight gain is not typically associated with tuberculosis (TB). In fact, weight loss is a common symptom of TB due to the chronic nature of the infection and the body’s increased metabolic demands to fight the disease. Patients with TB often experience a loss of appetite and significant weight loss as the disease progresses.
Choice B Reason:
Low-grade fever is a common symptom of TB. The body’s immune response to the infection often results in a persistent low-grade fever, which can be one of the early signs of the disease. This fever is usually accompanied by other systemic symptoms such as night sweats and fatigue.
Choice C Reason:
Dyspnea, or difficulty breathing, can occur in patients with TB, especially if the infection has caused significant lung damage or if there is a large amount of fluid in the pleural space (pleural effusion). Dyspnea is a concerning symptom that indicates the need for further evaluation and treatment.
Choice D Reason:
Contusion, or bruising, is not a symptom associated with TB. TB primarily affects the lungs and can cause systemic symptoms, but it does not typically cause bruising. Contusions are more commonly associated with trauma or conditions that affect blood clotting.
Choice E Reason:
Lethargy, or a general sense of fatigue and weakness, is a common symptom of TB. The chronic nature of the infection and the body’s ongoing immune response can lead to significant fatigue. Patients with TB often feel tired and may have difficulty performing daily activities.
Choice F Reason:
Night sweats are a hallmark symptom of TB. Patients often experience drenching night sweats that can be quite severe. This symptom, along with fever and weight loss, is part of the classic triad of TB symptoms and is an important indicator for healthcare providers to consider TB in the differential diagnosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is F
Explanation
Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication
Choice A Reason:
Assessment: Patient denies vomiting
This choice is not directly related to the effectiveness of Kayexalate. Vomiting can be a symptom of hyperkalemia, but the absence of vomiting does not indicate that the medication is working. Kayexalate works by binding potassium in the intestines and removing it through the stool, so the presence of bowel movements is a more direct indicator of its effectiveness.
Choice B Reason:
ECG: Flattening of QRS complex angle
Flattening of the QRS complex angle is not a typical ECG change associated with hyperkalemia or its treatment. Hyperkalemia typically causes widening of the QRS complex, and effective treatment would normalize this. Therefore, this choice is not correct.
Choice C Reason:
ECG: Widening of the QRS complex
Widening of the QRS complex is a sign of hyperkalemia, not its resolution. If the medication is effective, the QRS complex should return to a normal width. Therefore, this choice is not correct.
Choice D Reason:
Assessment: Patient consumed 60% of meal
While nutritional intake is important, it is not a direct indicator of the effectiveness of Kayexalate. The medication’s effectiveness is better assessed by changes in potassium levels and related symptoms, not by meal consumption.
Choice E Reason:
Assessment: Patient denies nausea
Similar to vomiting, nausea can be a symptom of hyperkalemia, but the absence of nausea does not indicate that the medication is working. The effectiveness of Kayexalate is better assessed by the presence of bowel movements and changes in potassium levels.
Choice F Reason:
Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication
This is the correct answer. Kayexalate works by binding potassium in the intestines and removing it through the stool. The presence of bowel movements indicates that the medication is working to remove potassium from the body. This is a direct and relevant assessment finding.
Choice G Reason:
ECG: Shortening of P wave duration
Shortening of the P wave duration is not a typical ECG change associated with hyperkalemia or its treatment. Therefore, this choice is not correct.
Choice H Reason:
Assessment: Patient denies pain
Pain is not a typical symptom of hyperkalemia, and its absence does not indicate that the medication is working. Therefore, this choice is not correct.
Choice I Reason:
ECG: Reduction of T wave amplitude
Reduction of T wave amplitude can be a sign of hypokalemia, not hyperkalemia. Effective treatment of hyperkalemia would normalize the T wave amplitude, not reduce it. Therefore, this choice is not correct.
Correct Answer is ["B","C","E"]
Explanation
Choice A: Lean on your back with your knees bent.
Reason: This instruction is incorrect. Pursed lip breathing is typically performed in a seated position with the neck and shoulders relaxed. Lying on your back with knees bent is not a recommended position for this breathing technique.
Choice B: Use your abdominal muscles to squeeze air out of your lungs.
Reason: This instruction is correct. Using the abdominal muscles helps to expel air more effectively from the lungs, which is a key component of pursed lip breathing. This technique helps to improve ventilation and reduce the work of breathing.
Choice C: Breathe out slowly without puffing your cheeks.
Reason: This instruction is correct. Breathing out slowly through pursed lips without puffing the cheeks helps to keep the airways open longer, allowing more air to be expelled from the lungs. This technique is particularly beneficial for individuals with chronic obstructive pulmonary disease (COPD) or other respiratory conditions.
Choice D: Focus on inhaling and holding your breath as long as you can.
Reason: This instruction is incorrect. The focus of pursed lip breathing is on controlled exhalation rather than holding the breath. Inhaling should be done slowly through the nose, and exhaling should be prolonged through pursed lips.
Choice E: Exhale at least twice the amount of time it took to breathe in.
Reason: This instruction is correct. The exhalation phase should be longer than the inhalation phase, typically taking at least twice as long. This helps to improve the efficiency of breathing and reduce shortness of breath.
Choice F: Open your mouth and breathe deeply.
Reason: This instruction is incorrect. Pursed lip breathing involves breathing in through the nose and exhaling through pursed lips. Opening the mouth and breathing deeply is not part of this technique.
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