Which finding(s) should the nurse expect to assess in a 16-year-old client diagnosed with cystic fibrosis admitted to the hospital for decreased results on pulmonary function tests (PFTs)?
Meconium ileus.
Blood-streaked sputum.
Clear breath sounds bilaterally.
Dyspnea.
The Correct Answer is B
Choice A rationale:
Meconium ileus is a concern in newborns with cystic fibrosis due to thick meconium, which can cause intestinal obstruction. At 16 years old, this complication is not relevant to the client's current condition.
Choice B rationale:
Blood-streaked sputum is a likely finding in a 16-year-old with cystic fibrosis and decreased pulmonary function. Cystic fibrosis leads to mucus accumulation and lung infections, which can cause blood vessels to rupture, resulting in blood-streaked sputum.
Choice C rationale:
Clear breath sounds bilaterally indicate healthy lung function, which is not expected in a client with cystic fibrosis and decreased PFT results. Breath sounds are likely to be diminished due to mucus accumulation.
Choice D rationale:
Dyspnea, or difficulty breathing, is a common symptom in clients with cystic fibrosis and decreased pulmonary function. However, the question asks about the expected findings that the nurse should assess, not a symptom that the client might report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A rationale:
Hypoplastic left heart syndrome involves inadequate development of the left side of the heart, leading to systemic hypoperfusion. It is characterized by decreased pulmonary blood flow due to underdeveloped left heart structures.
Choice B rationale:
Tetralogy of Fallot is characterized by obstruction to blood flow, specifically pulmonary stenosis, which obstructs blood flow from the right ventricle to the pulmonary artery.
Choice C rationale:
Atrial Septal Defect (ASD) is a left-to-right shunt, leading to increased pulmonary blood flow. This occurs because oxygenated blood from the left atrium flows back into the right atrium and then into the pulmonary circulation.
Choice D rationale:
Aortic Stenosis is not correctly matched with its hemodynamic classification. Aortic stenosis involves obstruction to blood flow from the left ventricle to the aorta.
Correct Answer is A
Explanation
Choice A rationale:
Children with nephrotic syndrome are at an increased risk of infection due to loss of immunoglobulins and other immune-related proteins in the urine, along with the use of immunosuppressive medications. The proteinuria associated with nephrotic syndrome leads to hypoalbuminemia and decreased immunity, making the child susceptible to infections, particularly bacterial peritonitis. Preventive measures include proper hand hygiene, maintaining a clean environment, and timely administration of prescribed antibiotics.
Choice B rationale:
Hypertension is not a primary complication of nephrotic syndrome in children. While they may have fluid retention and edema, resulting in increased blood pressure, infection is a more significant concern.
Choice C rationale:
Weight loss is not a typical complication of nephrotic syndrome but rather the opposite. Children with nephrotic syndrome often experience weight gain due to fluid retention and edema.
Choice D rationale:
Hyperkalemia is a possible electrolyte imbalance in nephrotic syndrome, but it is not a primary concern for children with this condition. The loss of protein in the urine can lead to hypoalbuminemia and subsequent edema, but hyperkalemia is not a common initial complication.
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