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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 A

Explanation

A. Vitamin D deficiency is a modifiable risk factor because it can be addressed through dietary changes, supplements, and increased sun exposure.

B. A small-boned, thin frame is considered a nonmodifiable risk factor as it is a genetic characteristic that cannot be changed.

C. A personal history of fractures is also a nonmodifiable risk factor, as past fractures indicate an increased risk for future fractures and cannot be altered.

D. Age is a nonmodifiable risk factor, as it is an intrinsic characteristic that cannot be changed

A. Planning B. Assessment C. Implementation D. Evaluation

Correct Answer is B

Explanation

A. The planning phase involves setting goals and determining interventions based on the assessment data.

B. The assessment phase is where the nurse gathers information about the client's health history, including potential allergies, which is essential for safe care and diagnostic testing.

C. The implementation phase involves carrying out the planned interventions, which would include considerations for allergies but not the initial questioning about them.

D. The evaluation phase assesses the effectiveness of the interventions and the client's response to care, which is not the appropriate time to inquire about allergies.

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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.

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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.