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 A
Explanation
A. Chocolate contains caffeine and cocoa, both of which can relax the lower esophageal sphincter (LES) and increase the risk of acid reflux. Additionally, chocolate is high in fat, which can further exacerbate symptoms of GERD. Therefore, chocolate is often recommended to be avoided by individuals with GERD.
B. Oatmeal is generally considered a bland and low-acid food that is unlikely to trigger symptoms of GERD. In fact, oatmeal is often recommended as part of a GERD-friendly diet due to its high fiber content, which can help absorb stomach acid and promote digestive health.
C. Apples are generally considered to be low in acid and high in fiber, making them a relatively safe fruit choice for individuals with GERD. However, some individuals may find that certain varieties of apples or apple products (such as apple juice) can exacerbate their GERD symptoms.
D. Nonfat milk is generally considered to be a low-fat and low-acid beverage that is unlikely to trigger symptoms of GERD. However, some individuals may find that consuming dairy products, including milk, can exacerbate their GERD symptoms.
Correct Answer is B
Explanation
B. The alveoli are tiny air sacs within the lungs where gas exchange occurs. Oxygen from inhaled air diffuses across the thin walls of the alveoli into the bloodstream, while carbon dioxide moves from the bloodstream into the alveoli to be exhaled.
A. The bronchi are the main airways that branch off from the trachea and lead to the lungs. While the bronchi play a crucial role in conducting air to and from the lungs, gas exchange does not occur in the bronchi themselves.
C. The nasal passages, also known as the nostrils or nares, are the passages through which air enters the respiratory system. While the nasal passages warm, humidify, and filter the air as it enters the body, gas exchange does not occur in this area.
D. The larynx, or voice box, is located at the top of the trachea and is involved in breathing, swallowing, and vocalization. However, gas exchange does not occur in the larynx.
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