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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Leg edema is primarily a manifestation of right-sided heart failure, where increased systemic venous pressure leads to fluid accumulation in dependent extremities. Left-sided heart failure, in contrast, primarily causes pulmonary congestion due to backward flow into the pulmonary circulation.
Choice B rationale
Anorexia can be a general symptom of advanced heart failure, particularly right-sided, due to visceral congestion and impaired gastrointestinal perfusion. However, it is not an initial or primary indicator specifically for left-sided heart failure.
Choice C rationale
Dyspnea, or shortness of breath, is a hallmark manifestation of left-sided heart failure. When the left ventricle fails, blood backs up into the pulmonary circulation, increasing pulmonary capillary hydrostatic pressure. This forces fluid into the interstitial spaces and alveoli, impairing gas exchange and causing breathlessness.
Choice D rationale
Hypotension (low blood pressure) can occur in severe, decompensated heart failure due to reduced cardiac output, but it is not typically an early or primary sign of developing left-sided heart failure. Often, the body initially compensates to maintain blood pressure.
Correct Answer is A
Explanation
Choice A rationale
Human immunodeficiency virus (HIV) is transmitted through specific body fluids, including blood, semen, pre-ejaculatory fluid, rectal fluids, vaginal fluids, and breast milk. Standard precautions are universally applied infection control practices designed to prevent transmission of infectious agents from recognized or unrecognized sources in healthcare settings. This includes hand hygiene and the use of personal protective equipment.
Choice B rationale
Respiratory isolation, such as airborne or droplet precautions, is implemented for diseases spread via airborne particles or respiratory droplets. HIV is not transmitted through the airborne or droplet route; therefore, respiratory isolation is an unnecessary and inappropriate measure for routine care of an HIV-positive individual.
Choice C rationale
Contact isolation is employed for infections spread by direct or indirect contact with the client or their environment, such as methicillin-resistant Staphylococcus aureus. HIV is not primarily transmitted through casual contact or fomites; thus, contact isolation is not indicated for the daily care of an HIV-positive individual.
Choice D rationale
An isolation gown is a component of personal protective equipment used in contact or droplet isolation to prevent contamination of clothing from splashes or sprays of infectious materials. Since HIV transmission requires direct contact with specific body fluids, a gown is not routinely necessary for providing care unless exposure to such fluids is anticipated. .
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