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

A. Lying on the left side does not aid in abdominal palpation and may not provide additional diagnostic information.
B. Asking the client to exhale and hold their breath is useful in certain liver or gallbladder assessments but is not relevant for general abdominal palpation.
C. Raising the head off the pillow is a technique used to assess for diastasis recti or hernias but is not beneficial for assessing right lower quadrant pain.
D. Assisting the client in flexing their knees is correct because it relaxes the abdominal muscles, reducing guarding and making palpation more effective. This is especially important when assessing for conditions like appendicitis.

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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Naxlex Comprehensive Predictor Exams

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

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?

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

The nurse is assessing vital signs and is preparing to measure the client's blood pressure. Prior to obtaining the blood pressure, what action would be most appropriate?

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 complains of shortness of breath and having to sleep on three pillows to breathe comfortably at night. During the nurse's examination, what findings will suggest that the cause of this client's dyspnea is due to a heart condition rather than respiratory disease?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?