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A nurse in an emergency department (ED) is admitting a client.

Exhibits

Select 4 findings in the client's medical record that place them at risk for pneumonia.

Pneumococcal vaccine

Level of consciousness

Influenza vaccine

Health history

Fluid intake

Age

Smoking history

Answer and Explanation

Correct Answer : B,D,E,F

A.   The client has not received the pneumococcal vaccine, but pneumococcal vaccination would help prevent pneumonia, particularly from Streptococcus pneumoniae. However, because the client has not had the vaccine, this option would be a risk factor for pneumonia, but it is not an immediate concern in terms of assessing the current risks in their medical record.
B.   The client appears lethargic and has difficulty answering questions due to shortness of breath, which suggests a decrease in the level of consciousness. Decreased mental status or level of consciousness increases the risk of aspiration, which can lead to pneumonia. For example, an altered level of consciousness makes it harder for patients to protect their airways (e.g., coughing or swallowing properly), which may increase the risk of aspiration and subsequent infection.
C.   The client has not received the influenza vaccine, which does increase the risk of contracting
pneumonia, especially if the person develops influenza. However, the patient’s primary issue is likely already in progress, so this is another unvaccinated status contributing to risk rather than an immediate finding.
D.   The client’s medical history is notable for no significant conditions other than the acute issue at hand. However, the lack of a pneumococcal vaccine (despite being at higher risk due to age) and not receiving the annual influenza vaccination can contribute to the development of pneumonia. Pneumonia is more common in individuals who do not receive these vaccines, as they provide protection against common respiratory pathogens, including Streptococcus pneumoniae and influenza viruses.
E.   The client reports decreased fluid intake over the past 24 hours due to a sore throat, which increases the risk of dehydration. Dehydration can lead to thicker mucus, making it more difficult to clear respiratory secretions. This increases the likelihood of bacterial growth and the development of pneumonia.
F.   The client is 70 years old, which places them at higher risk for pneumonia. Older adults have a weakened immune system, and their respiratory function may not be as effective as in younger individuals, making it easier for infections such as pneumonia to take hold. Age is a significant risk factor for more severe respiratory infections.
G.   There is no mention of smoking history in the social history provided, so it cannot be included as a risk factor for pneumonia in this case. Smoking is a known risk factor for respiratory infections, but since it isn’t specified here, we cannot assume it is relevant.

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Correct Answer is B

Explanation

A. Trapezius: The trapezius is a muscle of the upper back and neck and does not play a primary role in normal respiration.
B. Diaphragm: The diaphragm is the most important muscle for respiration. It contracts and moves downward during inhalation, increasing the thoracic cavity's volume and drawing air into the lungs.
C. Rectus abdominus: The rectus abdominus is a core muscle that helps in forced expiration but is not essential in normal breathing.
D. Sternocleidomastoid: This muscle assists with forced inspiration, but it is not the primary muscle for regular breathing.

A. Cervical B. Epitrochlear C. Inguinal D. Axillary

Correct Answer is D

Explanation

A. Cervical nodes drain the head and neck area, not typically the forearm or hand.
B. Epitrochlear nodes are found near the elbow and are responsible for draining the arm. The nurse would assess these nodes if the infection is in the arm or hand.
C. Inguinal nodes drain the lower extremities and groin area, not the upper extremities.
D. Axillary nodes drain the upper limbs, including the forearm and hand, and are likely to be swollen if there is an infection in the upper extremities.

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A nurse in an emergency department (ED) is admitting a client. Exhibits Select 4 findings in the client's medical record that place them at risk for pneumonia.

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A nurse in an emergency department (ED) is admitting a client.

Exhibits

Select 4 findings in the client's medical record that place them at risk for pneumonia.