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 C
Explanation
Choice A rationale
A 2+ deep tendon reflex (DTR) is considered a normal or average response, indicating an intact reflex arc with appropriate muscle contraction. This finding would not support a clinical assessment of diminished deep tendon reflexes or generalized weakness.
Choice B rationale
A 0 deep tendon reflex indicates no response, signifying a complete absence of the reflex. While this indicates a diminished reflex, generalized weakness often presents with hyporeflexia, but usually not a total absence unless there is severe neurological damage.
Choice C rationale
A 1+ deep tendon reflex indicates a diminished or sluggish response, which is consistent with hyporeflexia. This finding supports the clinical assessment of diminished deep tendon reflexes and generalized weakness often observed in clients post-cerebrovascular accident.
Choice D rationale
A 4+ deep tendon reflex indicates hyperreflexia, which is a hyperactive response often associated with clonus. This finding would be indicative of an upper motor neuron lesion and would contradict an assessment of diminished deep tendon reflexes and weakness. .
Correct Answer is B
Explanation
Choice A rationale
Cleaning the ears to remove excess wax buildup is inappropriate here because the description explicitly states the tympanic membranes (TMs) are visible and translucent gray, indicating no significant wax obstruction. Ear wax, or cerumen, naturally protects the ear canal; excessive buildup typically manifests as obscured TMs or hearing impairment, neither of which is present.
Choice B rationale
Recording the findings in the client's record is the most appropriate action. The presence of dense white patches on the tympanic membranes, known as tympanosclerosis, is a common sequela of chronic otitis media and typically represents calcification within the TM, not active infection or hearing loss. Given no current symptoms, this is an expected, benign finding.
Choice C rationale
Culturing the white patches for possible fungal growth is not indicated. Tympanosclerosis is a non-infectious, degenerative process involving hyaline degeneration and calcification of the TM, often following inflammation. Fungal infections of the ear typically present with different characteristics, such as otorrhea, pruritus, or pain, none of which are reported here.
Choice D rationale
Referral to an audiologist for a hearing evaluation is not immediately necessary. The client reports no hearing loss, and while tympanosclerosis can sometimes impact hearing, especially if extensive, the current lack of symptoms and clear visualization of landmarks suggest a stable, non-acute condition. An audiogram would be indicated if hearing changes were reported.
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