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 A
Explanation
A. Tachycardia is a common sign of hyperthyroidism, as elevated thyroid hormones increase heart rate and metabolic rate.
B. Dyspnea is not typically associated with hyperthyroidism; more commonly, hyperthyroid patients experience tachypnea (increased rate of breathing), but not necessarily dyspnea.
C. Constipation is more commonly associated with hypothyroidism, where metabolic slowing occurs.
D. Atrophied nodular thyroid gland is not typical of hyperthyroidism; a goiter (enlarged thyroid) is more commonly seen.
Correct Answer is ["A","B","E"]
Explanation
A. The timing of the murmur (systolic or diastolic) is an essential component of murmur assessment. It
helps in determining the cause of the murmur, whether it’s related to heart valves or flow.
B. Radiation refers to where the murmur can be heard best, or if it radiates to other parts of the chest or neck, helping to indicate the origin of the murmur.
C. Fremitus is a term used to describe the vibrations felt on the chest wall when a person speaks, which is unrelated to heart murmurs.
D. Egophony refers to an abnormal lung sound heard during auscultation and is not relevant to the assessment of a heart murmur.
E. The location where the murmur is heard best on the chest wall is crucial in determining its origin, such as whether it is coming from the aortic or mitral valve.
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