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 C

Explanation

A. Palpation of the thyroid helps assess its size, consistency, and tenderness but does not aid in detecting a bruit.
B. Swallowing helps assess the mobility of the thyroid but does not aid in auscultating for a bruit.
C. The bell of the stethoscope is used to detect low-pitched sounds, such as a bruit, which might be heard if there is increased blood flow through the thyroid gland, as seen in hyperthyroidism or Graves' disease.
D. The diaphragm is used to detect high-pitched sounds, such as lung or heart sounds. The bell is better for detecting a bruit.

A. Client's blood pressure B. Client's weight C. Client's respiratory rate D. Intensity of the murmur E. Location of the murmur F. Client's temperature G. Timing of the murmur H. Client's medication history

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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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

A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the gland for the presence of a bruit. What technique should the nurse use to assess for a bruit?

Correct Answer is C

Explanation

A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

Correct Answer is ["A","D","E","G"]

Explanation

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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?