An 84-year-old client has been admitted to the emergency department from an extended care facility. The facility staff suspect pneumonia and it is noted that the client has a productive cough, shortness of breath, and abnormal breath sounds. The nurse assesses the client's vital signs and notes an oral temperature of 97.5°F. How should the nurse interpret this assessment finding?

The client's infection is no longer localized and has become systemic.

The client likely has a cardiac health problem, not a respiratory health problem.

The client's signs and symptoms are related to hypothermia rather than infection.

The client's normothermic temperature does not rule out the presence of an infection.

Answer and Explanation

The Correct Answer is D

A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.

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Correct Answer is D

Explanation

D. "Client denies recent constipation, diarrhea, bowel incontinence, or abdominal pain." is correct because it is the most specific and complete documentation of the client’s subjective report. It ensures clarity, accuracy, and thorough assessment.
A. This is incorrect because stating "within normal limits" is vague and does not specify what was assessed.
B. This is incorrect because stating "problems are not present" is too general and does not include specific symptoms the client was asked about.
C. This is incorrect because "denies gastrointestinal signs and symptoms" lacks specificity regarding which symptoms were assessed.

A. The right lung is approximately one third larger than the left lung. B. The lower lobes of both lungs are primarily located toward the anterior chest wall. C. The right lung has three lobes, while the left lung has two lobes. D. The lungs are structurally symmetrical but functionally different.

Correct Answer is C

Explanation

A. The right lung is larger than the left to accommodate the heart’s position, but it is not precisely one third larger.
B. The lower lobes of both lungs are primarily located toward the posterior chest wall, not the anterior. When auscultating breath sounds in the lower lobes, the nurse should focus on the posterior thorax.
C. The right lung has three lobes (upper, middle, and lower), while the left lung has two lobes (upper and lower). This anatomical difference is important for respiratory assessment and auscultation.
D. The lungs are not structurally symmetrical; the left lung is smaller due to the cardiac notch. While there are minor functional differences, the primary distinction is anatomical.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While the nurse is assessing a client's gastrointestinal system, the nurse's findings are unremarkable and the client denies complications. How would the nurse best document the subjective portion of the assessment?

Correct Answer is D

Explanation

The nurse is preparing to perform a focused respiratory assessment on a client. The nurse should be cognizant of what anatomical characteristic of the lungs?

Correct Answer is C

Explanation

The nurse is assessing an older adult client in the emergency room. Upon assessment, the nurse notes that the client is in the tripod position, has dyspnea at rest, wheezing upon auscultation, and an oxygen saturation level of 91%. What significant health problem might the nurse suspect?

The nurse identifies that the patient care tech recorded the client's blood pressure as 78/52. The nurse recognizes this blood pressure is abnormally low for this client. What is the best response by the nurse?

The nurse is inspecting a new client's abdomen and notes the presence of a tight, distended abdomen and visible arterioles on the abdominal skin surface. What would the nurse do next?

The nurse's auscultation of a client's lung fields reveals the presence of a wheeze. The nurse should recognize that this adventitious sound results from what pathophysiologic process?

While assessing a client's abdomen, the nurse observes sharp pains and involuntary reflex guarding on expiration. What complication does the nurse suspect based on these findings?

A client has sought care because they are concerned that a mole on the scalp may be skin cancer. Which finding would the nurse identify as being most suggestive of melanoma?

A nurse is utilizing the Braden Scale for Predicting Pressure Sore Risk during the admission assessment of an older adult client. What assessment parameter will the nurse evaluate when using this scale?

A nurse has completed the review of systems component of the client's health history. Which assessment finding should the nurse document under the review of systems?