The patient with emphysema comes to the emergency department with difficulty breathing. What finding should the nurse anticipate during data collection? Select all that apply
diminished breath sounds
ruddy skin color
use of accessory muscles
excess mucus production
barrel shaped chest
Correct Answer : A,C,E
A. Diminished breath sounds can occur in emphysema due to decreased air movement through damaged and enlarged air sacs (alveoli). The destruction of alveolar walls reduces the surface area available for gas exchange and can result in decreased breath sounds.
C. Patients with emphysema may use accessory muscles, such as neck and shoulder muscles, to assist with breathing during periods of respiratory distress. These muscles are recruited to help increase the size of the thoracic cavity and improve airflow.
E. A barrel-shaped chest is a common physical finding in patients with emphysema. It results from hyperinflation of the lungs and is characterized by an increased anterior-posterior diameter of the chest. This change in chest shape is due to air trapping in the lungs, leading to overinflation of the alveoli and increased residual volume.
B. Ruddy skin color, which refers to a reddish or flushed complexion, is not typically associated with emphysema. Instead, patients with emphysema may exhibit cyanosis (bluish discoloration of the skin) during periods of hypoxemia (low oxygen levels).
D. Excess mucus production (mucus hypersecretion) is a characteristic feature of chronic bronchitis, which is often present alongside emphysema in chronic obstructive pulmonary disease (COPD) but it is not typically a primary feature of emphysema itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B. Maintaining a healthy weight is important for managing a hiatal hernia. Excess body weight can increase abdominal pressure and exacerbate symptoms. Weight loss, if necessary, can help reduce the frequency and severity of symptoms.
C. Elevating the head of the bed helps prevent the reflux of stomach contents into the esophagus while sleeping. Gravity helps keep the stomach contents down, reducing the risk of acid reflux and associated symptoms.
D. Caffeine and spicy foods can irritate the stomach lining and exacerbate symptoms of hiatal hernia, such as heartburn and acid reflux. Reducing the intake of these foods can help manage symptoms.
A. This is not typically a recommendation for managing a hiatal hernia. Drinking fluids is important for overall health and digestion. However, it is advisable to avoid drinking large amounts of fluids quickly, especially with meals, as this can increase intra-abdominal pressure and worsen symptoms.
E. Lying down after meals can increase the risk of reflux and worsen symptoms of a hiatal hernia. It is generally recommended to remain upright for at least a couple of hours after eating to prevent reflux.
Correct Answer is B
Explanation
B. An elevated white blood cell (WBC) count, specifically an elevation in the neutrophil count (neutrophilia), is commonly seen in pneumonia. It indicates an inflammatory response to the infection and is a typical finding in bacterial pneumonia.
A. A decreased serum creatinine level is not typically associated with pneumonia and may not be directly related to the condition. In fact, it may suggest impaired kidney function or dehydration, but it is not a concerning lab abnormality specifically related to pneumonia.
C. Protein in the urine (proteinuria) may be present in various conditions, including kidney disease, urinary tract infections, and certain systemic illnesses. While it can sometimes be seen in severe cases of pneumonia, it is not a specific or common finding associated with the condition.
D. Decreased serum potassium levels are not typically associated with pneumonia itself. However, certain factors related to pneumonia treatment or complications, such as the use of diuretics or vomiting, could lead to hypokalemia. While hypokalemia can have serious consequences, it is not directly related to the severity of pneumonia.
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