A client arrives at the physician's office stating 2 days of febrile illness, dyspnea, and cough. Upon assisting the client into a gown, the nurse notes that the client's sternum is depressed, especially on inspiration. Crackles are noted in the bases of the lung fields. Based on inspection, which will the nurse document?

The client has pneumonia in the bases.

The client has chronic respiratory disease.

The client has a funnel chest.

The client needs a cough suppressant.

Answer and Explanation

The Correct Answer is C

A. The client has pneumonia in the bases: Crackles in the lung bases can suggest pneumonia; however, this finding alone does not confirm a diagnosis. Diagnosis requires clinical correlation with imaging findings such as consolidation or opacities and possibly labs. The physical deformity of the chest (sternal depression) is unrelated to the presence of pneumonia.
B. The client has chronic respiratory disease: While dyspnea and crackles may be seen in chronic respiratory diseases like COPD, the inspection finding of a depressed sternum is not characteristic of these conditions. An illness occurring for two days is also acute and cannot be termed chronic. Documenting a structural deformity based on inspection is more accurate than assuming a chronic disease.
C. The client has a funnel chest: Funnel chest, or pectus excavatum, is a deformity marked by a sunken appearance of the sternum, often more noticeable on inspiration. This is an accurate inspection-based finding that the nurse should document, separate from the respiratory symptoms.
D. The client needs a cough suppressant: A cough suppressant is a potential treatment option for symptomatic relief, but this does not relate to the inspection finding. The nurse’s role at this point is assessment and documentation, not treatment decisions based solely on visual inspection.

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Correct Answer is B

Explanation

A. Strengthen venous valves: Damaged or weakened venous valves cannot be physically strengthened through exercise or compression. Management focuses on symptom relief and preventing progression rather than structural repair.
B. Improve venous return: Exercise, elevation, and compression stockings all assist in promoting blood flow back to the heart. These measures reduce venous stasis and swelling, improving circulation in clients with venous insufficiency.
C. Improve arterial flow: This regimen targets the venous system rather than arterial circulation. Arterial flow is typically addressed through interventions like vasodilators, smoking cessation, and walking programs for peripheral artery disease.
D. Increase venous congestion: This regimen is designed to reduce, not increase, venous congestion. Elevation and compression help counteract pooling of blood in the lower extremities, a hallmark of venous insufficiency.

A. The client is not at risk for infection from microorganisms. B. Trauma and microabrasions from a non-electric razor may contribute to anemia. C. Strong tissues and intact clotting mechanisms may prevent hemorrhage. D. The client is at risk for spontaneous and uncontrolled bleeding.

Correct Answer is D

Explanation

A. The client is not at risk for infection from microorganisms: Leukemia and its treatment often cause immunosuppression, making clients more vulnerable to infections. This statement is inaccurate in the context of leukemia care.
B. Trauma and microabrasions from a non-electric razor may contribute to anemia: Minor skin injuries do not directly cause anemia, which in leukemia results from bone marrow suppression. However, these injuries can lead to bleeding, which is a greater concern.
C. Strong tissues and intact clotting mechanisms may prevent hemorrhage: Clients with leukemia often have impaired clotting due to thrombocytopenia. Assuming normal clotting is inappropriate, as these clients may bleed excessively even with minor trauma.
D. The client is at risk for spontaneous and uncontrolled bleeding: Thrombocytopenia is common in leukemia, increasing the risk of bleeding from even minor cuts. An electric razor minimizes the chance of skin injury and is a safety measure to prevent hemorrhage.

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Naxlex Comprehensive Predictor Exams

A client with venous insufficiency is instructed to exercise, apply elastic stockings, and elevate the extremities. Which is the primary benefit for this nursing management regimen

Correct Answer is B

Explanation

The nurse caring for an older adult with a diagnosis of leukemia would encourage the client to use an electric razor. What is the rationale for this statement by the nurse?

Correct Answer is D

Explanation

A client is unconscious on arrival to the emergency department. The nurse in the emergency department identifies that the client has a permanent pacemaker due to which characteristic?

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