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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Wheezing is a high-pitched, musical sound produced by narrowed airways. It is a common and classic finding in asthma due to the bronchoconstriction that occurs during an asthma exacerbation. The presence of wheezing on auscultation is a strong indicator of asthma, as it reflects the turbulent airflow through constricted bronchi.
B. Normal breath sounds would generally not indicate asthma. In the absence of an asthma attack or during periods of remission, a person with asthma might have normal breath sounds. However, during an asthma exacerbation, the breath sounds are more likely to be abnormal, such as wheezing or decreased breath sounds if airflow is severely compromised.
C. Clear lung sounds on auscultation would typically indicate that there are no abnormal sounds such as wheezes, crackles, or rhonchi. In the context of asthma, clear lung sounds could be heard if the asthma is well-controlled or if the client is not currently experiencing an exacerbation.
D. A decreased respiratory rate (bradypnea) is not a typical finding in asthma. During an asthma exacerbation, clients often experience tachypnea (increased respiratory rate) due to difficulty breathing and the increased effort required to breathe.

A. 25 year-old with left arm sling B. 72 year-old with incontinence and dementia C. 82 year-old with an ankle fracture D. 45 year-old post total hysterectomy

Correct Answer is B

Explanation

A. Although this client has an arm sling, which could potentially limit movement and cause some localized pressure, they are generally at a lower risk for widespread skin breakdown compared to older adults. Their younger age and lack of other risk factors make them less susceptible overall.
B. Older adults have thinner skin and decreased elasticity, making them more susceptible to pressure ulcers and skin breakdown. Frequent exposure to moisture from urine or feces can lead to skin irritation and breakdown, especially in areas where skin is already compromised.
C. While an elderly individual with an ankle fracture is at risk for skin breakdown, especially if immobilized and in a cast, this risk is somewhat less immediate compared to someone with incontinence.
D. This client is recovering from surgery, which could include temporary changes in mobility or activity levels. However, they are younger and do not have the additional complicating factors like incontinence or dementia. While there is some risk of skin issues post-surgery, it is not as high as the risk posed by incontinence and cognitive impairment in an elderly client.

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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.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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