A nurse is collecting data from a client who has pulmonary tuberculosis. Which of the following findings should the nurse expect?
Fatigue
High fever in the early morning
Edema
Increased appetite
The Correct Answer is A
A. Fatigue
When collecting data from a client with pulmonary tuberculosis (TB), the nurse should expect to observe fatigue as one of the common manifestations. TB is a bacterial infection caused by Mycobacterium tuberculosis, primarily affecting the lungs. Fatigue is a typical symptom experienced by individuals with TB, often resulting from the body's immune response to the infection, as well as the systemic effects of inflammation and tissue damage caused by the bacteria.
B. High fever in the early morning
While fever is a symptom of tuberculosis, it may not necessarily occur specifically in the early morning. Fever associated with TB can occur at any time of the day and may persist for weeks to months. The pattern of fever can vary among individuals and may not consistently occur in the early morning.
C. Edema
Edema, or swelling due to fluid accumulation in tissues, is not typically associated with pulmonary tuberculosis. Edema is more commonly observed in conditions such as heart failure, renal failure, or liver disease, rather than in TB.
D. Increased appetite
Increased appetite is not a typical finding in pulmonary tuberculosis. In fact, individuals with active TB infection often experience appetite loss and unintended weight loss due to factors such as decreased food intake, metabolic changes, and systemic inflammation associated with the infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The patient's Spo2 is 97% on 2L NC:
This assessment finding indicates that the patient's oxygen saturation level (SpO2) is 97% while receiving 2 liters per minute of oxygen via nasal cannula. Oxygen saturation is a measure of the percentage of hemoglobin saturated with oxygen in the blood. A SpO2 level of 97% suggests adequate oxygenation, which is essential for effective gas exchange. Therefore, if the patient's SpO2 is within the target range on the prescribed oxygen therapy, it indicates that the interventions aimed at improving gas exchange have been effective.
B. The patient appears comfortable:
While patient comfort is important, it is not a direct indicator of effective gas exchange. A patient may appear comfortable for various reasons, such as pain relief, proper positioning, or emotional support, but this does not necessarily reflect improved gas exchange. Therefore, while comfort is an important aspect of nursing care, it is not specifically indicative of the effectiveness of interventions for impaired gas exchange.
C. The patient is coughing up copious white sputum:
The presence of copious white sputum does not directly indicate improved gas exchange. White sputum may suggest various conditions, such as respiratory tract infections or inflammation, but it does not provide direct information about gas exchange efficiency. Effective gas exchange involves the exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, which cannot be assessed solely based on sputum production.
D. The patient is able to move out of bed without difficulty:
The ability to move out of bed without difficulty may indicate improved overall physical function or mobility, but it does not specifically reflect improved gas exchange. Gas exchange primarily involves the transfer of oxygen from the alveoli into the bloodstream and the removal of carbon dioxide from the bloodstream into the alveoli for exhalation. While improved gas exchange may lead to enhanced physical endurance and reduced dyspnea, the ability to move out of bed without difficulty is not a direct measure of gas exchange efficiency.
Correct Answer is ["A","C","E"]
Explanation
A. Inspiratory stridor
Inspiratory stridor is a high-pitched, musical sound heard during inspiration that indicates partial obstruction of the upper airway. It is a characteristic sign of airway obstruction and requires immediate attention.
B. Nausea
Nausea is not a common manifestation of airway obstruction. It may be associated with other conditions such as gastrointestinal issues or medication side effects but is not directly related to airway obstruction.
C. Retractions
Retractions refer to visible sinking of the skin between the ribs and above the clavicles during inspiration, which indicates increased effort to breathe. Retractions can occur in response to airway obstruction, as the body attempts to overcome the resistance to breathing.
D. Muscle tremors
Muscle tremors are not specific manifestations of airway obstruction. Tremors may occur due to various reasons such as anxiety, electrolyte imbalances, or neurological conditions but are not typically associated with airway obstruction.
E. Cyanosis
Cyanosis is a bluish discoloration of the skin and mucous membranes resulting from inadequate oxygenation of the blood. It can occur with airway obstruction as oxygen exchange is compromised. Cyanosis is a late sign of respiratory distress and requires immediate intervention.
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