Which assessment finding is most likely to be immediately life-threatening?

Bronchial breath sounds over a peripheral lung field

Soft high-pitched expiratory wheezing with forced expiration.

Absent breath sounds over one lung lobe

Stridor

Answer and Explanation

The Correct Answer is D

A.   While abnormal bronchial breath sounds can indicate underlying pathology, they are not typically considered immediately life-threatening.
B.   Wheezing is a common symptom of asthma and other conditions that cause airway narrowing. While it can be uncomfortable and distressing, it is not typically considered a life-threatening emergency.
C.   Absent breath sounds can indicate a collapsed lung or other serious respiratory condition. However, it is not as immediately life-threatening as stridor, which indicates a severe airway obstruction.
D.   Stridor is a high-pitched, wheezing sound caused by obstruction or narrowing of the upper airway (larynx or trachea). It is often associated with conditions like croup, epiglottitis, or an allergic reaction leading to airway swelling. Stridor indicates a significant obstruction in the upper airway that can rapidly lead to severe respiratory distress or compromise.

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Correct Answer is C

Explanation

A. This position is often seen in clients with chronic respiratory conditions like emphysema. It is called the tripod position and can help the client breathe more easily by expanding the chest and reducing the work of breathing. While this position indicates the client is experiencing difficulty breathing, it is not an immediate emergency but rather a sign of their chronic respiratory condition.

B. Fine crackles (or rales) are abnormal lung sounds that can indicate fluid in the alveoli. In emphysema, crackles are not typical and may suggest a complication such as pulmonary edema or infection.
However, if these crackles are not severe and the client’s overall condition is stable, it may not be the
most urgent issue compared to other findings.
C. A respiratory rate of 9 breaths per minute is considered bradypnea, which is significantly lower than the normal range (12-20 breaths/min). For a client with chronic emphysema on oxygen therapy, bradypnea is a concerning finding because it indicates inadequate respiratory drive and potential respiratory depression.
D. A barrel chest is a common physical finding in clients with chronic emphysema due to chronic air trapping and lung overexpansion. It reflects long-standing changes in the chest structure due to the disease. While it is a notable finding, it is a chronic manifestation of emphysema and not an immediate concern in the context of acute clinical status.

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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Which assessment finding is most likely to be immediately life-threatening?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating and assessing a client with a diagnosis of chronic emphysema. The client is receiving oxygen therapy at a flow rate of 5 L/min via nasal cannula. Which findings concern the nurse immediately?

Correct Answer is C

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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