A nurse is caring for a client diagnosed with advanced COPD. The nurse should anticipate which assessment findings when caring for clients with advanced COPD? (Select all that apply.)

Elevated temperature.

Pursed-lip breathing.

Clubbing of the fingers.

Concave chest.

Dyspnea at rest.

Answer and Explanation

Correct Answer : B,D,E

A. Elevated temperature: Elevated temperature is not typically associated with advanced COPD unless there is an underlying infection. Infections such as pneumonia may exacerbate COPD symptoms but are not universal findings in advanced COPD.

B. Pursed-lip breathing: Pursed-lip breathing is a common compensatory mechanism seen in clients with COPD. It helps to slow down the rate of expiration and prevents alveolar collapse, improving gas exchange.

C. Clubbing of the fingers: Clubbing of the fingers is not typically associated with COPD. It is more commonly seen in conditions such as chronic hypoxemia, congenital heart disease, and certain lung diseases like bronchiectasis.

D. Concave chest: In advanced COPD, the chest may appear hyperinflated with a barrel-shaped chest due to air trapping. The presence of a concave chest is not characteristic of COPD.

E. Dyspnea at rest: Dyspnea, or difficulty breathing, is a hallmark symptom of COPD. In advanced stages, clients may experience dyspnea even at rest due to severe airflow limitation and impaired gas exchange.

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Correct Answer is D

Explanation

A. 18% is inaccurate

B. 44% is inaccurate

C. 36% is inaccurate

D. According to the Rule of Nines:

Each arm is typically assigned 9% (4.5% for each arm). The chest and abdomen together are assigned 18%.

The upper back is assigned 9%.

The lower back is assigned 9%.

Each leg is typically assigned 18% (9% for each leg). Adding these percentages together for the described burns:

9% (each arm) + 18% (chest and abdomen) + 9% (upper back) + 9% (lower back) = 54%

A. Client has increased urine specific gravity. B. Changes in the client's behavior. C. Client is complaining of nausea. D. Client is complaining of severe headache. E. Client's urine output is only 50 cc/hr.

Correct Answer is ["A","B","C","D"]

Explanation

A. Client has increased urine specific gravity: Increased urine specific gravity indicates concentrated urine, which is a hallmark of SIADH and should be reported as it reflects the excessive retention of water.

B. Changes in the client's behavior: Behavioral changes can be indicative of hyponatremia, a serious complication of SIADH, and should be reported immediately.

C. Client is complaining of nausea: Nausea is a symptom of hyponatremia, which is a common and dangerous consequence of SIADH that needs prompt attention.

D. Client is complaining of severe headache: A severe headache can also be a sign of hyponatremia and potential cerebral edema, both of which are critical conditions needing urgent intervention.

E. Client's urine output is only 50 cc/hr: While reduced urine output can be associated with SIADH, 50 cc/hr is not extremely low and might not be immediately alarming on its own. The other symptoms are more critical and should take precedence in reporting to the provider.

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A nurse is caring for a client diagnosed with advanced COPD. The nurse should anticipate which assessment findings when caring for clients with advanced COPD? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has burns on both arms, chest, abdomen and upper and lower back. Utilizing the Rule of Nines, the nurse estimates that the extent of the client's burns is which of the following percentages?

Correct Answer is D

Explanation

A nurse is caring for a client who is exhibiting manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

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