The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?
Absent deep tendon reflexes.
Capillary refill less than 3 seconds.
3+ peripheral dependent edema.
Oxygen saturation of 85%.
The Correct Answer is D
A. Absent deep tendon reflexes are not typically associated with nailbed clubbing. While reflexes may be diminished in some conditions, they are not commonly related to the pathophysiology behind clubbing.
B. A capillary refill time of less than 3 seconds is a normal finding and does not align with clubbing, which often indicates chronic hypoxia or systemic conditions such as heart or lung disease.
C. Peripheral dependent edema refers to swelling in the lower extremities, which can be associated with circulatory problems, but it is not directly linked to nailbed clubbing. Edema is more common in conditions like heart failure or kidney disease.
D. A low oxygen saturation of 85% is consistent with conditions that cause chronic hypoxia, such as chronic lung disease or congenital heart disease. Chronic low oxygen levels can lead to nailbed clubbing as a compensatory response to inadequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tenting of the skin is a classic sign of dehydration. When the skin is pinched and does not return quickly to its normal position, it indicates a lack of fluid in the body. This is a common finding in dehydration, particularly in older adults.
B. Loss of skin elasticity is a natural part of the aging process and may not be directly related to dehydration. It is common in older adults and is not necessarily an indicator of fluid status.
C. Warm and dry skin can be a sign of dehydration, particularly if accompanied by other symptoms such as a dry mouth or increased heart rate. Dry skin occurs when there is insufficient moisture in the body, which is common in dehydration.
D. Thinning hair in the lower extremities is more often associated with circulation issues or aging. It is not a typical sign of dehydration and would not be used as a primary indicator for assessing hydration status.
Correct Answer is D
Explanation
A. This is not specific for egophony. While lung auscultation is part of a thorough assessment, egophony is assessed when the patient vocalizes a specific sound, not just breathing in and out.
B. This is a technique used to assess for whispered pectoriloquy, not egophony. The nurse would be looking for clarity of the whispered words, which is different from assessing for egophony.
C. This test is used to assess for bronchophony, where the nurse listens for clarity or increased volume of spoken words over the lungs. It is not related to egophony, which is a change in the sound when the client says "E."
D. This is the correct method for assessing egophony. In this test, the client is asked to say "E," and the nurse listens for any change in the sound. Normally, the "E" should sound like "E." If it sounds like "A," it indicates egophony, which can suggest a lung consolidation, such as might occur with a lung abscess.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.