When assessing the elderly patient, the nurse observes that the anterior to posterior width is the same as the transverse width of the chest. When documenting her findings, she describes this as:

Barrel Chest

Chronic Obstructive Pulmonary Disease

Anterior/Posterior Distortion

Lordosis

Answer and Explanation

The Correct Answer is A

A) Barrel Chest: This term describes a condition where the anterior-posterior (AP) diameter of the chest is equal to the transverse diameter, giving the chest a rounded appearance. This finding is often observed in older adults or individuals with chronic respiratory conditions, and it indicates a potential increase in lung volume and air trapping, commonly seen in conditions like emphysema or chronic obstructive pulmonary disease (COPD).

B) Chronic Obstructive Pulmonary Disease: While barrel chest can be associated with COPD, it is not a direct descriptor of the chest shape. COPD encompasses various symptoms and physiological changes but does not specifically define the chest's physical appearance as barrel-shaped.

C) Anterior/Posterior Distortion: This term does not accurately describe the findings observed in the assessment. While it suggests some alteration in chest shape, it does not specifically refer to the characteristic appearance of barrel chest, which is a well-defined clinical term.

D) Lordosis: This refers to an excessive inward curve of the spine, particularly in the lumbar region. While it may affect posture and overall body alignment, it does not relate to the chest shape or measurements, making it an inappropriate choice in this context.

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Correct Answer is ["A","B","D"]

Explanation

For a thorough assessment of the integumentary system, the nurse should provide the following instructions:

A. "Please remove all jewellery so that I can conduct a full assessment."

This is correct. Jewelry can obstruct the assessment of skin, especially in areas like the neck, chest, and hands, where it may cover or hide skin abnormalities.

B. "I will be touching your skin as part of the process."

This is correct. A thorough integumentary assessment involves palpating the skin to check for texture, moisture, temperature, and other characteristics. It's important for the client to be informed that touch will be involved.

C. "I will turn the temperature down in the exam room before we begin." "Use this blanket to cover up until we are ready to begin."

This is partially correct. The temperature in the exam room should be comfortable, but turning it down may not be necessary. The instruction to cover with a blanket is appropriate to preserve the client's privacy and warmth until the assessment begins.

D. "I will need you to take off your head dress for the entire examination."

This is correct. If the head dress covers the scalp or areas that need to be examined (like the scalp, ears, or face), it should be removed to allow for a full assessment of the integumentary system.

A. Chronic pain B. Intractable pain C. Acute pain D. End-of-life pain

Correct Answer is C

Explanation

A) Chronic pain: Chronic pain is defined as pain that lasts for an extended period, often longer than three months, and is usually associated with conditions that are ongoing or recurring. The client’s symptoms, including sudden-onset severe pain and accompanying acute symptoms like nausea and vomiting, do not align with the characteristics of chronic pain.

B) Intractable pain: Intractable pain refers to pain that is resistant to treatment and does not respond well to analgesics or other interventions. While the client's pain is severe, the sudden onset and associated symptoms suggest a specific acute process rather than a pain condition that is inherently resistant to treatment.

C) Acute pain: Acute pain is characterized by its sudden onset and typically corresponds to a specific injury or condition, often with accompanying physiological responses such as nausea and restlessness. The client’s severe pain rating of 10, along with nausea and vomiting, strongly indicates that they are experiencing acute pain, likely related to an underlying acute abdominal condition.

D) End-of-life pain: End-of-life pain usually occurs in patients with terminal illnesses and is often managed with palliative care strategies. The client’s sudden onset of severe pain and accompanying symptoms indicate a different situation, likely not related to a terminal condition.

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When assessing the elderly patient, the nurse observes that the anterior to posterior width is the same as the transverse width of the chest. When documenting her findings, she describes this as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for a thorough assessment of the integumentary system. Which instructions should the nurse provide the client? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

Correct Answer is C

Explanation

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