Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Lymph nodes are usually described as enlarged or swollen, not "lumped." This term is not typically used in the description of lymphadenopathy.
B. In cases of acute infection, lymphadenopathy is most often unilateral and localized to the area of infection. For example, if there is a throat infection, the lymph nodes on the same side of the neck are more likely to be enlarged.
C. Lymph nodes that are soft and nontender are more indicative of chronic conditions such as lymphoma or metastasis. In acute infections, lymph nodes tend to be firm and tender.
D. Firm but freely movable nodes may be indicative of chronic conditions or noninfectious causes. Acute infection typically leads to tender, swollen lymph nodes that may feel rubbery or hard but are usually movable.

A. Smoking, hypertension, obesity, diabetes, and high cholesterol B. Personality type, high cholesterol, diabetes, and smoking C. Alcohol consumption, obesity, diabetes, stress, and high cholesterol D. Family history, hypertension, stress, and age

Correct Answer is A

Explanation

A. Smoking, hypertension, obesity, diabetes, and high cholesterol: These are all well-established major risk factors for heart disease and should be included in the patient's history.
B. Personality type, high cholesterol, diabetes, and smoking: While personality type may contribute to stress, the other factors listed are more directly linked to heart disease.
C. Alcohol consumption, obesity, diabetes, stress, and high cholesterol: Alcohol consumption may be a risk factor, but smoking and hypertension are more significant.
D. Family history, hypertension, stress, and age: While family history, age, and hypertension are important, this option misses key factors like obesity, smoking, and diabetes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear?

Correct Answer is B

Explanation

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?

Correct Answer is A

Explanation

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find:

The nurse is assessing a lesion on a patient and observes a focal loss of epidermis and dermis, a depression extending into the dermis, irregularly shaped, and bleeding. This type of wound is known as a/an

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another?

Which of the following is the most important muscle in the normal respiratory process of an adult?

A client presents with an infection of the forearm and hand. The nurse should expect what lymph nodes to be swollen on assessment:

A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, what finding would lead the nurse to suspect that this may not be a cancerous thyroid nodule?

The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination?

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.