When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

There is a history of COPD.

The client has a collapsed lung

The client's lungs are functioning normally.

A chronic lung infection is the likely condition.

Answer and Explanation

The Correct Answer is B

A. Chronic Obstructive Pulmonary Disease (COPD) can lead to decreased lung function and abnormalities in lung expansion. However, COPD typically results in a more generalized decrease in lung expansion and breath sounds, rather than pronounced unilateral inequality. While COPD can cause irregularities in lung expansion, it is less likely to cause significant unilateral differences in lung expansion.
B. Unequal lung expansion is a key sign of a collapsed lung, or pneumothorax. When a lung collapses, the affected side will show reduced or absent expansion compared to the unaffected side. This is because the collapsed lung cannot expand properly during inhalation, leading to noticeable differences in breath sounds and lung movement on physical examination.
C. If the client's lungs were functioning normally, one would expect to observe symmetrical lung expansion. Unequal lung expansion is not a normal finding and usually indicates some form of pathology or abnormality in the lung or thoracic cavity. Normal lung function should result in even expansion of both lungs.
D. Chronic lung infections, such as tuberculosis or severe pneumonia, might cause abnormalities in lung sounds or localized lung issues, but they are less likely to cause pronounced unilateral differences in lung expansion. While they can affect lung function, they typically do not cause the same degree of unilateral expansion issues as a pneumothorax would.

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Correct Answer is C

Explanation

A. A standing position leaning over the exam bed may not provide the best view or allow for thorough examination of the perianal area. This position is less commonly used and may not be ideal for a focused assessment of hemorrhoids.
B. Finding out if the client uses over-the-counter preparations for hemorrhoids provides useful information about the management and treatment approach being used. However, while this information is valuable, it does not directly involve the physical assessment of the hemorrhoids themselves.
C. The left lateral position (also known as the Sims' position) is commonly used for the examination of the perianal area. It provides optimal access for visual inspection of hemorrhoids, fissures, or other abnormalities in the anal region. This position allows the nurse to examine the area more thoroughly and comfortably, making it the most appropriate choice for a focused assessment of hemorrhoids.

D. Asking about the duration of discomfort provides valuable information about the history and progression of the condition. Understanding how long the client has been experiencing symptoms can help in assessing the chronicity and possible treatment history of the hemorrhoids.

A. “Move closer and place a hand on the client's shoulder to demonstrate concern”. B. “Ignore the angry outburst and continue with the history questions”. C. "You sound angry. Would you like to tell me about it?" D. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

Correct Answer is C

Explanation

A. While physical touch, such as placing a hand on the client’s shoulder, can sometimes be reassuring, it might not always be appropriate or welcomed, especially if the client is already expressing frustration or anger. It’s important to assess the client's comfort with physical contact before proceeding with such gestures.
B. Ignoring the client's angry outburst is not advisable because it fails to acknowledge the client’s feelings and may escalate their frustration. Addressing emotional responses is crucial in maintaining a therapeutic relationship and ensuring that the client feels heard and respected.
C. This response is the best choice because it acknowledges the client’s emotional state and invites them to share their feelings. By addressing the client's anger directly and expressing a willingness to listen, the nurse helps to validate the client’s emotions and opens the door for a more productive dialogue.
D. While this response acknowledges the client's feelings, it might come across as dismissive of their immediate needs and could imply that their concerns are not worth addressing at this time. It also does not actively engage with the client's emotions or attempt to resolve the frustration.

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When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

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