A nurse in an emergency department (ED) is admitting a client. Select 3 findings in the client's medical record that may be indicative of bronchitis.
temperature
complaint of fatigue
respiratory assessment
use of accessory muscles
blood pressure
bowel sounds
Correct Answer : A,C,D
A. An elevated temperature is often associated with infections and inflammation, including bronchitis. While a temperature of 99°F is slightly above normal and may indicate a mild fever, it is not a primary hallmark of bronchitis but rather a common response to infection or inflammation.
B. Fatigue is a general symptom that can accompany many conditions, including bronchitis. It is related to the overall feeling of being unwell and is not specific to bronchitis. While fatigue can be present, it is not a definitive sign of bronchitis on its own.
C. This includes findings such as bronchial breath sounds and rhonchi (a type of coarse, rattling sound) noted in the right lower lobe, which are indicative of bronchitis. The presence of rhonchi and bronchial breath sounds suggest inflammation and mucus in the airways, characteristic of bronchitis.
D. The use of accessory muscles for breathing is a sign of respiratory distress, which can occur in bronchitis when the airways are inflamed and obstructed. This finding is consistent with bronchitis as it reflects the increased effort required to breathe due to airway inflammation and mucus production.
E. The blood pressure reading of 110/54 mm Hg is within normal limits and does not provide specific information about bronchitis. Blood pressure is not typically a primary indicator for diagnosing bronchitis.
F. Bowel sounds are related to gastrointestinal function and do not provide information specific to bronchitis. Active bowel sounds are normal and do not help in diagnosing bronchitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Assessing the client’s respirations is crucial in evaluating their respiratory status. This includes
checking the rate, rhythm, depth, and effort of breathing. Given the client’s symptoms of cough and lung congestion, it's important to assess whether there are any signs of respiratory distress or abnormal breathing patterns.
B. Auscultating lung sounds is essential to identify any abnormal lung sounds such as wheezes, crackles, or rhonchi. This helps in evaluating the presence and severity of lung congestion and can provide insights into the underlying cause of the client's symptoms.
C. While assessing peripheral pulses is important in a comprehensive cardiovascular assessment, it is not directly related to evaluating symptoms of a cold, cough, or lung congestion. The focus of the assessment for these specific symptoms would be more on the respiratory system.
D. Checking the client’s temperature is important because a fever may indicate an infection or inflammation, which can be associated with the symptoms of a cold or lung congestion. This helps in assessing the overall systemic response to the infection.
E. A musculoskeletal and neurological examination is not directly relevant to assessing symptoms related to a cold, cough, or lung congestion. These exams are more appropriate for evaluating physical function and neurological status, which are not the primary concerns in this scenario.
F. While family history can provide valuable context for some conditions, it is not the immediate focus for evaluating current symptoms like a cold, cough, or lung congestion. The priority should be on the present symptoms and their immediate effects on the client’s health.
Correct Answer is B
Explanation
A. While mammograms are commonly used to evaluate breast tissue in women, they are not typically used for men. In men, gynecomastia is usually evaluated with a physical exam and sometimes ultrasound rather than mammography. A mammogram might be ordered if there is a suspicion of breast cancer, but this is less common and not the first step in evaluating gynecomastia.
B. This is a prudent and effective next step. Certain medications can cause gynecomastia as a side effect, including some antipsychotics, antidepressants, antiandrogens, and calcium channel blockers. Reviewing the medication list can help identify if the gynecomastia might be related to a drug the client is taking.
C. A breast biopsy is an invasive procedure used to diagnose breast cancer or other conditions when there is a concern about a mass or abnormality. If gynecomastia is the only finding and there are no concerning features such as a palpable mass or other symptoms, a breast biopsy would not be the first step.
D. While gynecomastia can occur as a normal part of aging, especially in older men due to hormonal changes, it is important to evaluate it thoroughly to rule out other causes. Simply dismissing it as a normal part of aging without further investigation might overlook an underlying condition or medication side effect.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.