A nurse is caring for a 36-year-old male client on a medical-surgical unit.
Based on the client’s current status, which should the nurse include in a focused assessment?
Observe the client’s respirations for rate, rhythm, and depth
Inspect the skin and mucus membranes
Measure the apical pulse for 60 seconds
Auscultate chest
Have the client demonstrate use of the incentive spirometer
Determine the heart rhythm
Correct Answer : A,B,D,E
Choice A rationale: Observing respirations for rate, rhythm, and depth is crucial in pneumonia management as respiratory compromise may develop rapidly. Changes in respiratory pattern such as tachypnea, irregular rhythm, or shallow breaths can indicate worsening lung function, hypoxia, or impending respiratory failure, requiring immediate intervention.
Choice B rationale: Inspecting skin and mucous membranes helps assess for signs of hypoxia or poor perfusion, such as cyanosis or pallor. These findings can indicate inadequate oxygen delivery due to impaired lung function in pneumonia. Monitoring skin integrity is also important for infection control and early detection of complications.
Choice C rationale: Measuring the apical pulse for 60 seconds is important in cardiac assessments, especially if arrhythmias or murmurs are suspected. However, in pneumonia without cardiac symptoms or abnormal heart sounds, continuous assessment of apical pulse is not prioritized in a focused respiratory assessment.
Choice D rationale: Auscultating the chest is essential to evaluate breath sounds for signs of consolidation, crackles, or diminished air entry, which directly reflect pneumonia severity and progression. Regular auscultation helps guide treatment decisions and detect complications like pleural effusion or pneumothorax.
Choice E rationale: Having the client demonstrate incentive spirometer use ensures proper technique, promoting lung expansion and preventing atelectasis. Correct use reduces pulmonary complications and supports recovery, making it an important part of nursing assessment and education in pneumonia care.
Choice F rationale: Determining heart rhythm is important in cardiac assessments, but in the absence of arrhythmia symptoms or abnormal ECG findings, it is not a primary focus in pneumonia care. Monitoring vital signs regularly is sufficient unless clinical indications suggest otherwise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
An enlarged thyroid gland, or goiter, suggests potential dysfunction of the thyroid, which produces hormones essential for metabolism. Requesting diagnostic laboratory testing, such as thyroid-stimulating hormone (TSH), T3, and T4 levels, is crucial to evaluate thyroid function, identify hyperthyroidism or hypothyroidism, and guide appropriate medical management. Normal TSH is 0.4-4.0 mIU/L.
Choice B rationale
Scheduling a follow-up without immediate investigation delays diagnosis and potential treatment for a condition that could significantly impact the client's metabolic health. Thyroid enlargement warrants prompt assessment to determine its underlying cause, which could range from benign hyperplasia to more serious conditions requiring intervention.
Choice C rationale
While iodine deficiency can cause goiter, instructing on iodized salt use without diagnostic confirmation is premature and potentially inappropriate. Other causes exist, and excessive iodine intake can sometimes worsen thyroid conditions or induce dysfunction. A thorough assessment is paramount before recommending dietary changes.
Choice D rationale
Obtaining a dietary consultation is not the primary action for an enlarged thyroid gland. While diet can influence thyroid health, the immediate priority is to assess the gland's function and identify the underlying pathological process through laboratory and possibly imaging studies, before considering nutritional interventions.
Correct Answer is C
Explanation
Choice A rationale
Borborygmi refers to loud, prolonged gurgles, or rumbling sounds, often audible without a stethoscope, indicating increased bowel motility. While the sounds described are gurgles, their frequency (every 5-10 seconds) and distribution across all quadrants suggest a normal physiological process rather than the excessive, prolonged, and often hyperactive sounds characteristic of borborygmi.
Choice B rationale
Hyperactive bowel sounds are characterized by frequent, loud, and high-pitched sounds, occurring more than 30 times per minute. The described gurgles occurring every 5 to 10 seconds (6 to 12 sounds per minute) do not meet the criteria for hyperactive bowel sounds, which would indicate significantly increased intestinal motility often associated with conditions like diarrhea or gastroenteritis.
Choice C rationale
Normal bowel sounds are typically soft gurgles or clicks, occurring irregularly at a rate of 5 to 30 times per minute. The nurse's finding of gurgles lasting about 3 seconds and occurring every 5 to 10 seconds in all quadrants falls within this normal range, indicating appropriate intestinal peristalsis and function throughout the digestive tract.
Choice D rationale
Hypoactive bowel sounds are infrequent and quiet, occurring less than 5 times per minute. The described frequency of gurgles, occurring every 5 to 10 seconds (6 to 12 sounds per minute), is much more frequent than what would be classified as hypoactive, which often suggests decreased bowel motility due to conditions such as ileus or constipation.
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