A nurse is admitting a client with an exacerbation of chronic obstructive pulmonary disease.
What signs would the nurse expect to observe with this client? Select all that apply.
A BMI greater than 30%.
Clubbing in upper digits.
AP chest diameter of 1:1.
Tripod positioning.
High amounts of energy.
Correct Answer : B,D
Clubbing in upper digits and tripod positioning are signs of chronic obstructive pulmonary disease (COPD), a respiratory disorder that has components of chronic bronchitis and emphysema. Clubbing is a thickening and widening of the fingertips and nails due to chronic low oxygen levels in the blood. Tripod positioning is when the person leans forward and supports their arms on a table or chair to facilitate breathing.
Choice A is wrong because a BMI greater than 30% indicates obesity, which is not a specific sign of COPD, although it can worsen the condition.
Choice C is wrong because AP chest diameter of 1:1 means that the chest is as wide as it is deep, which is also known as barrel chest. This is a sign of emphysema, one of the components of COPD, but not of COPD itself.
Choice E is wrong because high amounts of energy are not associated with COPD. On the contrary, people with COPD often experience fatigue, weakness, and reduced exercise tolerance due to impaired gas exchange and respiratory muscle function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should prioritize the physical safety and stability of the patient who has been raped and stabbed.
Assessing vital signs is the first step in determining the patient’s condition and identifying any life-threatening injuries that need immediate intervention.
Choice A is wrong because calling the Sexual Nurse Examiner is not the first action to take.
The Sexual Nurse Examiner is a specially trained nurse who can perform a forensic examination and collect evidence from the patient, but this should be done after ensuring the patient’s physical safety and obtaining consent.
Choice C is wrong because calling her parents to ask for permission to treat her is not necessary or appropriate.
The patient is an adult who can consent to her own treatment unless she is incapacitated or mentally incompetent.
Calling her parents without her permission may violate her privacy and autonomy.
Choice D is wrong because contacting Security in case the perpetrator arrives is not the most urgent action to take.
The nurse should focus on the patient’s needs and not assume that the perpetrator will follow her to the hospital.
Security measures can be taken later if needed.
Correct Answer is D
Explanation
A heart murmur is a priority assessment for a toddler who is diagnosed with fetal alcohol syndrome because it may indicate a congenital heart defect, which can affect the child’s growth, development and oxygenation. According to the health search results, fetal alcohol syndrome can cause heart and kidney problems, among other complications.
Choice A is wrong because small head size is a common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has microcephaly, which is associated with intellectual and learning disabilities.
Choice B is wrong because poor coordination is another common feature of fetal alcohol syndrome, but it is not a priority assessment. It indicates that the child has problems with motor skills and balance.
Choice C is wrong because speech and language delays are also common features of fetal alcohol syndrome, but they are not a priority assessment. They indicate that the child has problems with communication and social skills.
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