The nurse assesses that a client has nailbed clubbing.
Which additional information is consistent with this finding?
3+ peripheral dependent edema.
Oxygen saturation of 85%.
Absent deep tendon reflexes.
Capillary refill less than 3 seconds.
The Correct Answer is B
Choice A rationale
3+ peripheral dependent edema indicates significant fluid retention in the extremities, often associated with cardiovascular or renal dysfunction. While it reflects systemic issues, it is not directly linked to nailbed clubbing, which primarily arises from chronic tissue hypoxemia affecting distal capillaries.
Choice B rationale
Nailbed clubbing is a clinical sign strongly associated with chronic hypoxemia, where oxygen saturation levels are persistently low. An oxygen saturation of 85% indicates significant hypoxemia (normal range 95-100%), which can lead to the compensatory vascular changes and connective tissue proliferation observed in clubbing.
Choice C rationale
Absent deep tendon reflexes suggest neurological impairment, often related to peripheral neuropathy or spinal cord issues. This finding is unrelated to nailbed clubbing, which is a manifestation of prolonged systemic hypoxia, not nerve damage or reflex arcs.
Choice D rationale
Capillary refill less than 3 seconds indicates adequate peripheral perfusion and is considered a normal finding (normal range <3 seconds). This contrasts with nailbed clubbing, which is indicative of impaired oxygenation and not typically associated with normal capillary refill times.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Percussing diaphragmatic excursion assesses the movement of the diaphragm during respiration, reflecting lung expansion and function. While relevant to respiratory assessment, it does not directly confirm the anatomical characteristic of a barrel chest, which is a structural alteration of the thoracic cage.
Choice B rationale
Auscultating breath sounds evaluates airflow through the respiratory passages, identifying adventitious sounds like wheezes or crackles. Although individuals with a barrel chest may have altered breath sounds due to lung hyperinflation, auscultation does not directly confirm the physical presence of the barrel chest deformity itself.
Choice C rationale
Observing the appearance of the thorax allows for direct visual assessment of the anteroposterior (AP) diameter in relation to the transverse diameter. A barrel chest is characterized by an increased AP diameter, often approaching a 1: ratio, which is a key visual diagnostic criterion for this chronic respiratory condition.
Choice D rationale
Palpating tactile fremitus assesses the transmission of vibrations through the lung tissue during vocalization. While providing information about lung consolidation or obstruction, it is not a primary method for confirming the characteristic structural deformity of an increased anteroposterior diameter associated with a barrel chest.
Correct Answer is C
Explanation
Choice A rationale
This task assesses attention, concentration, and calculation abilities, which are components of cognitive function, but not primarily abstract thinking. Abstract thinking involves the ability to understand concepts and ideas that are not physically present.
Choice B rationale
This question assesses orientation to person and recent memory. It does not require the client to interpret symbolic meaning or understand concepts beyond the literal, which are hallmarks of abstract thought.
Choice C rationale
Abstract thinking involves the ability to interpret proverbs, metaphors, or figures of speech. Understanding "The early bird catches the worm" requires the client to grasp the underlying conceptual meaning beyond the literal words, demonstrating abstract reasoning.
Choice D rationale
This question assesses remote memory and ability to recall past events. While it provides insight into long-term memory and narrative coherence, it does not directly evaluate the capacity for abstract thought or conceptual understanding.
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