A Medical-Surgical nurse is performing an assessment on a client with a history of chronic obstructive pulmonary disease. Which of the following findings will the nurse most likely observe?

Unequal chest expansion.

Atrophied neck and trapezius muscle.

Increased tactile fremitus.

An anterior-to-posterior chest diameter ratio of 1:1.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Unequal chest expansion is the correct choice. In a patient with chronic obstructive pulmonary disease (COPD), the airways are often narrowed and obstructed, leading to difficulty in moving air in and out of the lungs. This can result in unequal chest expansion during breathing, where one side of the chest expands less than the other. This finding is commonly observed in patients with COPD due to the imbalance in lung function between different areas of the lungs.

Choice B rationale:

Atrophied neck and trapezius muscle is not a typical finding in COPD. Muscle atrophy can occur in conditions of prolonged disuse or immobility, but it is not a characteristic manifestation of COPD itself.

Choice C rationale:

Increased tactile fremitus refers to increased vibrations felt on the chest wall during speech. This finding is more commonly associated with conditions that cause lung consolidation, such as pneumonia. In COPD, there is often air trapping and hyperinflation of the lungs, which would not lead to increased tactile fremitus.

Choice D rationale:

An anterior-to-posterior chest diameter ratio of 1:1 is not a typical finding in a healthy individual, let alone in a patient with COPD. In COPD, there is often an increase in the anterior-to-posterior chest diameter ratio, giving the chest a barrel-like appearance. This is due to the trapped air and hyperinflation of the lungs, which is characteristic of the disease.

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Correct Answer is C

Explanation

Choice A rationale:

Visual observation for nonverbal signs of pain can be useful, especially in patients who are unable to communicate verbally. However, this method is not as accurate or reliable as obtaining the client's self-report of pain severity, which directly allows the patient to express their experience.

Choice B rationale:

Vital sign measurement, such as heart rate, blood pressure, and respiratory rate, can provide indirect information about a patient's pain level. However, vital signs can be influenced by various factors, including anxiety or other physiological responses. They may not always accurately reflect the intensity of pain and are not as specific as the client's self-report.

Choice C rationale:

The client's self-report of pain severity is the most reliable and accurate method for determining the intensity of pain. Pain is a subjective experience, and the client's self-report is crucial for effective pain management. Pain scales, such as numeric rating scales or visual analog scales, allow clients to describe their pain intensity in a standardized way.

Choice D rationale:

The nature and invasiveness of the surgical procedure are relevant factors to consider in understanding a patient's potential pain experience. However, this information alone is not sufficient for determining the current intensity of the client's pain. Pain levels can vary among individuals undergoing the same procedure due to differences in pain tolerance and perception.

A. Centers the cuff bladder over the client's brachial artery. B. Places the client's arm above the level of the client's heart. C. Wraps the blood pressure cuff snugly around the client's arm. D. Checks the instrument gauge to ensure the reading starts at zero.

Correct Answer is B

Explanation

Choice A rationale:

Placing the cuff bladder over the client's brachial artery is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff placement, which is essential for an accurate measurement.

Choice B rationale:

Placing the client's arm above the level of the client's heart is an incorrect action when obtaining a blood pressure reading. The client's arm should be supported at heart level to ensure accurate measurement. This choice indicates a need for further instruction as it could lead to an artificially low blood pressure reading.

Choice C rationale:

Wrapping the blood pressure cuff snugly around the client's arm is a correct action when obtaining a blood pressure reading. This choice demonstrates proper cuff application, which is necessary for accurate results.

Choice D rationale:

Checking the instrument gauge to ensure the reading starts at zero is a correct action when obtaining a blood pressure reading. This choice reflects a proper step to verify that the equipment is calibrated correctly.

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