Upon assessment, the nurse noted a temperature of 102.1, respirations of 30 breaths per minute, oxygen saturation of 90% on room air, decreased expansion and dullness over the right lung, and crackles heard on the right lower lobe. Which condition should the nurse suspect?

Atelectasis

Pulmonary obstruction

Pneumonia

Bronchitis

Answer and Explanation

The Correct Answer is C

A.   Atelectasis refers to the collapse or incomplete expansion of a lung or a portion of a lung. It can cause decreased breath sounds and dullness upon percussion, but it is less likely to present with a fever as high as 102.1°F. However, atelectasis can occur secondary to an obstructive pneumonia, making the distinction important in clinical settings.
B.   Pulmonary obstruction, such as from an obstruction of the airway or bronchus, might cause symptoms like difficulty breathing and decreased oxygen saturation. However, it would less commonly present with fever and localized crackles.
C.   Pneumonia often presents with symptoms such as fever (elevated temperature of 102.1°F), increased respiratory rate (30 breaths per minute), decreased oxygen saturation (90% on room air), and abnormal lung findings. The decreased expansion and dullness over the right lung, along with crackles (rales) heard in the right lower lobe, are indicative of fluid accumulation and inflammation in the lung, which are characteristic of pneumonia.
D.   Acute bronchitis involves inflammation of the bronchi and is often associated with a cough, sputum production, and sometimes fever. However, it typically presents with a productive cough and wheezing rather than localized dullness and crackles confined to one lobe.

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Correct Answer is B

Explanation

A. Palpable lymph nodes are assessed through palpation, not inspection. The nurse would use their hands to feel for lymph nodes in areas such as the axilla (armpit) and supraclavicular regions. This is a tactile examination and therefore not documented as part of the inspection.
B. Symmetry refers to the visual observation of whether the breasts are equal in size and shape. During the inspection phase, the nurse notes whether the breasts appear symmetrical or if there are any visible asymmetries.
C. Breast sensitivity is typically assessed through palpation or the client’s report of symptoms rather than through inspection alone. Sensitivity involves asking the client about their experience of pain or discomfort in the breasts, which cannot be observed visually.
D. Tenderness is assessed through palpation, where the nurse would gently press on the breast tissue to determine if the client experiences pain. Tenderness is not a visual finding and therefore is not documented during the inspection phase.

A. diabetic neuropathy. B. postherpetic neuralgia. C. visceral pain. D. trigeminal neuralgia.

Correct Answer is D

Explanation

A. Diabetic neuropathy is a type of nerve damage that occurs due to prolonged high blood sugar levels associated with diabetes. While diabetic neuropathy can cause pain, it's usually more generalized and affects extremities rather than specific areas like the mouth and teeth.
B. Postherpetic neuralgia is a condition that occurs as a complication of shingles (herpes zoster). It involves persistent nerve pain in the area where the shingles rash occurred, typically affecting the skin. The pain is usually described as burning or aching rather than stabbing, and it is localized to the area previously affected by the rash.
C. Visceral pain originates from the internal organs (viscera) and is typically described as a deep, aching, or cramping pain. It is often associated with conditions like gastrointestinal or gynecological issues.
D. Trigeminal neuralgia is a condition characterized by sudden, severe, sharp, stabbing pain along the distribution of the trigeminal nerve, which innervates the face. The pain can be triggered by activities such as brushing teeth, talking, or touching the face.

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Upon assessment, the nurse noted a temperature of 102.1, respirations of 30 breaths per minute, oxygen saturation of 90% on room air, decreased expansion and dullness over the right lung, and crackles heard on the right lower lobe. Which condition should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse document?

Correct Answer is B

Explanation

A client tells the nurse that they are experiencing stabbing pain in the mouth, gums, teeth, and chin following brushing her teeth. These are symptoms of

Correct Answer is D

Explanation

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