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

Exhibits

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.

decreased urine output

headache

respiratory assessment

Chest X-ray

Religion

Bowel sounds

perception of needles

Answer and Explanation

Correct Answer : A,C,D

A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.

B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.

C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.

D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.

E. Religion: This does not relate to the clinical findings associated with pneumonia.

F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.

G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.

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Correct Answer is B

Explanation

A. Observing for facial symmetry assesses cranial nerves VII (facial nerve) rather than cranial nerve III.

B. Checking the pupillary response to light assesses cranial nerve III (oculomotor nerve), which controls pupil constriction and extraocular eye movements.

C. Testing visual acuity assesses cranial nerve II (optic nerve), not cranial nerve III.

D. Eliciting the gag reflex assesses cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.

A. Severity of the condition B. Vital signs C. Nonverbal behavior D. Self-rating of pain

Correct Answer is D

Explanation

A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.

B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.

C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.

D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.

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A nurse in an emergency department (ED) is admitting a client. Exhibits Select 3 objective findings in the client's medical record that may be indicative of pneumonia.

Nursing Test Bank

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

Exhibits

Select 3 objective findings in the client's medical record that may be indicative of pneumonia.