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+
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Adrenal: The adrenal glands produce hormones like cortisol and adrenaline, but not thyroxine.
B. Parotid: The parotid glands are salivary glands and are unrelated to thyroxine production.
C. Thyroid: The thyroid gland produces thyroxine (T4), and elevated levels of this hormone indicate that the thyroid gland should be assessed for potential hyperthyroidism.
D. Parathyroid: The parathyroid glands regulate calcium levels but do not produce thyroxine.
Correct Answer is ["A","D","E","G"]
Explanation
A. Client's blood pressure is relevant as it can help correlate the murmur with potential cardiac conditions.
B. Client's weight is not directly related to documenting a heart murmur.
C. Client's respiratory rate is also not relevant to the murmur documentation unless respiratory symptoms are present.
D. Intensity of the murmur is important to document, as it helps assess the severity.
E. Location of the murmur is important for identifying which valve or area of the heart is involved.
F. Client's temperature is not directly related to documenting a heart murmur.
G. Timing of the murmur helps in identifying whether it occurs during systole or diastole, aiding in diagnosis.
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