A nurse assesses that a client diagnosed with advanced COPD is experiencing alteration in nutrition manifested by weight loss.
The nurse should recognize that the client's weight loss is related to which primary issue?

The client does not have access to preferred foods.

The client is unable to eat and breathe at the same time.

The client has lost interest in eating.

The client does not have energy to eat.

Answer and Explanation

The Correct Answer is B

Choice A rationale

This choice suggests a socioeconomic or access issue, which while possible, is not the primary physiological reason for weight loss specifically linked to advanced COPD. The core problem in COPD impacting nutrition is often directly related to the physiological demands of the disease itself.

Choice B rationale

In advanced COPD, increased respiratory effort leads to dyspnea, making it difficult to coordinate breathing with the act of eating. This results in reduced oral intake because clients become breathless during meals, leading to caloric deficit and subsequent weight loss due to decreased energy intake.

Choice C rationale

While depression and loss of appetite can occur in chronic illnesses, the primary mechanistic link between advanced COPD and weight loss is often the physical inability to consume adequate calories due to exertional dyspnea and the high metabolic demands of increased work of breathing.

Choice D rationale

Fatigue certainly contributes to overall debility in COPD, but the specific mechanism for weight loss is often directly tied to the physiological challenge of eating. The energy expenditure for breathing significantly increases, diverting energy from other functions and making the act of eating itself exhausting.

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Correct Answer is C

Explanation

Choice A rationale

Phantom breast pain is a neuropathic pain phenomenon that can occur after mastectomy, characterized by sensations of pain, itching, or tingling in the removed breast. While distressing for the client, it is a common neurological sequela and not typically considered an acute surgical complication indicating immediate danger.

Choice B rationale

A combination of numbness and pain around the breast incision is expected post-mastectomy. Numbness results from nerve transection during surgery, while pain is an anticipated consequence of tissue injury and inflammation. These are normal postoperative sensations, managed with analgesia, and do not typically signify a complication.

Choice C rationale

Lymphedema, characterized by swelling in the arm on the same side as the mastectomy, indicates a complication. It results from impaired lymphatic drainage due to lymph node removal or damage during surgery. This can lead to chronic swelling, discomfort, and increased risk of infection, requiring immediate intervention to manage and prevent progression.

Choice D rationale

A wound dressing saturated with blood every two hours indicates excessive bleeding, which is a significant complication post-mastectomy. While some serosanguineous drainage is normal, continuous saturation suggests active hemorrhage or a hematoma, requiring immediate assessment and potential surgical intervention to control the bleeding.

A. Elevated Hemoglobin. B. Elevated Troponins. C. Elevated B-type Natriuretic Peptide. D. Elevated Creatine Kinase (CK).

Correct Answer is B

Explanation

Choice A rationale

Hemoglobin levels are primarily indicative of the oxygen-carrying capacity of the blood and are not specific markers of cardiac injury. While low hemoglobin (anemia) can exacerbate myocardial ischemia, an elevated hemoglobin (normal range for males: 13.5-17.5 g/dL; females: 12.0-15.5 g/dL) does not signify cardiac cellular damage.

Choice B rationale

Troponins, specifically cardiac troponin I and T, are highly sensitive and specific biomarkers for myocardial necrosis. When cardiac muscle cells are damaged, these proteins are released into the bloodstream, making their elevation (normal range usually undetectable or very low) the most reliable indicator of cardiac injury.

Choice C rationale

B-type Natriuretic Peptide (BNP) is a neurohormone released primarily from ventricular myocytes in response to increased ventricular wall stretch and pressure. While elevated BNP (normal range typically <100 pg/mL) is a key marker for heart failure, it does not directly indicate acute myocardial cell death or injury.

Choice D rationale

Creatine Kinase (CK) is an enzyme found in various tissues, including skeletal muscle, brain, and heart. While an elevated total CK can indicate muscle damage, the CK-MB isoenzyme is more specific to cardiac muscle. However, troponins are now considered superior due to their higher specificity and earlier rise in acute MI compared to CK or CK-MB (normal CK levels: 22-198 U/L).

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A nurse assesses that a client diagnosed with advanced COPD is experiencing alteration in nutrition manifested by weight loss. The nurse should recognize that the client's weight loss is related to which primary issue?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client during the first 24 hours post mastectomy. Which of the following observations made by the nurse should indicate a complication from the mastectomy procedure?

Correct Answer is C

Explanation

A nurse is caring for a client with a possible acute myocardial infarction (MI). The electrocardiogram (ECG) shows no ST segment elevations or depression. The nurse is aware that an elevation of which lab result will determine if there has been cardiac injury?

Correct Answer is B

Explanation

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A nurse assesses that a client diagnosed with advanced COPD is experiencing alteration in nutrition manifested by weight loss.
The nurse should recognize that the client's weight loss is related to which primary issue?