A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Abdominal retraction

Clubbing nails

Restlessness

Dependent edema 4+

Answer and Explanation

The Correct Answer is B

A.   Abdominal retraction is typically a sign of acute respiratory distress, not chronic respiratory insufficiency.
B.   Clubbing nails occurs as a chronic response to inadequate tissue oxygenation and is often associated with conditions like chronic obstructive pulmonary disease (COPD).
C.   Restlessness may occur during acute respiratory distress but is not a typical finding in chronic respiratory insufficiency.
D.   Dependent edema 4+ is more related to cardiac conditions such as heart failure rather than respiratory insufficiency, which generally results in more subtle signs like clubbing or cyanosis.

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Correct Answer is A

Explanation

A. Smoking, hypertension, obesity, diabetes, and high cholesterol: These are all well-established major risk factors for heart disease and should be included in the patient's history.
B. Personality type, high cholesterol, diabetes, and smoking: While personality type may contribute to stress, the other factors listed are more directly linked to heart disease.
C. Alcohol consumption, obesity, diabetes, stress, and high cholesterol: Alcohol consumption may be a risk factor, but smoking and hypertension are more significant.
D. Family history, hypertension, stress, and age: While family history, age, and hypertension are important, this option misses key factors like obesity, smoking, and diabetes.

A. Fixed lymph nodes B. Lymph nodes that are large, firm, and fixed to the tissue C. Nonpalpable lymph nodes D. Rubbery, discrete, and mobile lymph nodes

Correct Answer is C

Explanation

A. Fixed lymph nodes suggest possible malignancy or infection and are not typical for a healthy individual.
B. Lymph nodes that are large, firm, and fixed to the tissue also suggest infection or malignancy and would be abnormal in a healthy patient.
C. Nonpalpable lymph nodes are a normal finding.
D. Rubbery, discrete, and mobile lymph nodes are indicative of a pathological process.

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A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect to find because of the long- term inadequate tissue perfusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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