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Which sign or symptom would the nurse anticipate in a patient diagnosed with tuberculosis? Select all that apply. One, some, or all responses may be correct.

Weight gain

Low-grade fever

Dyspnea

Contusion

Lethargy

Night sweats

Answer and Explanation

Correct Answer : B,C,E,F

Choice A Reason:

Weight gain is not typically associated with tuberculosis (TB). In fact, weight loss is a common symptom of TB due to the chronic nature of the infection and the body’s increased metabolic demands to fight the disease. Patients with TB often experience a loss of appetite and significant weight loss as the disease progresses.

Choice B Reason:

Low-grade fever is a common symptom of TB. The body’s immune response to the infection often results in a persistent low-grade fever, which can be one of the early signs of the disease. This fever is usually accompanied by other systemic symptoms such as night sweats and fatigue.

Choice C Reason:

Dyspnea, or difficulty breathing, can occur in patients with TB, especially if the infection has caused significant lung damage or if there is a large amount of fluid in the pleural space (pleural effusion). Dyspnea is a concerning symptom that indicates the need for further evaluation and treatment.

Choice D Reason:

Contusion, or bruising, is not a symptom associated with TB. TB primarily affects the lungs and can cause systemic symptoms, but it does not typically cause bruising. Contusions are more commonly associated with trauma or conditions that affect blood clotting.

Choice E Reason:

Lethargy, or a general sense of fatigue and weakness, is a common symptom of TB. The chronic nature of the infection and the body’s ongoing immune response can lead to significant fatigue. Patients with TB often feel tired and may have difficulty performing daily activities.

Choice F Reason:

Night sweats are a hallmark symptom of TB. Patients often experience drenching night sweats that can be quite severe. This symptom, along with fever and weight loss, is part of the classic triad of TB symptoms and is an important indicator for healthcare providers to consider TB in the differential diagnosis.

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Correct Answer is C

Explanation

Choice A Reason:

Telling his wife what the client needs is not the most effective discharge action. While it is important for the wife to understand the client’s needs, this approach is too passive and does not actively engage the client or his wife in the care process. Effective management of Parkinson’s disease requires active participation from both the client and the caregiver to ensure adherence to the care plan and to address any concerns or preferences they may have.

Choice B Reason:

Setting up visitations by a home health nurse can be beneficial, but it is not the most effective discharge action on its own. Home health nurses can provide valuable support and monitoring, but the success of the management plan also depends on the involvement and commitment of the client and his wife. Without their active participation, the care plan may not be fully effective.

Choice C Reason:

Involving the client and his wife in developing a plan of care is the most effective discharge action. This approach ensures that both the client and his wife are fully engaged in the care process, understand the management plan, and are more likely to adhere to it. Collaborative care planning allows for the consideration of the client’s and caregiver’s preferences, needs, and concerns, leading to a more personalized and effective care plan. This active involvement can also empower the client and his wife, improving their confidence in managing the disease.

Choice D Reason:

Writing up a detailed plan of care according to standards is important, but it is not the most effective discharge action if done in isolation. A standardized care plan may not address the unique needs and preferences of the client and his wife. Without their involvement in the development of the plan, there may be a lack of understanding or commitment to the care plan, reducing its effectiveness. Personalizing the care plan through active involvement of the client and his wife is crucial for successful management.

A. Client who displays plantar flexion when the bottom of the foot is stroked. B. Client who consistently demonstrates decortication when stimulated. C. Client whose Glasgow Coma Scale (GCS) has changed from 15 to 12. D. Client whose deep tendon reflexes have become hyperactive.

Correct Answer is C

Explanation

Choice A Reason:

The client who displays plantar flexion when the bottom of the foot is stroked is exhibiting a normal reflex response known as the plantar reflex. This response indicates that the corticospinal tract is functioning properly. In adults, the normal response is plantar flexion of the toes, which means the toes curl downward. This is not an immediate cause for concern and does not indicate a life-threatening condition.

Choice B Reason:

The client who consistently demonstrates decortication when stimulated is showing signs of severe brain injury. Decorticate posturing is characterized by the arms being flexed at the elbows and held tightly to the chest, with the legs extended and feet turned inward. This type of posturing indicates damage to the cerebral hemispheres, thalamus, or midbrain. While this is a serious condition, it is not necessarily the most immediate priority compared to a sudden change in the Glasgow Coma Scale.

Choice C Reason:

The client whose Glasgow Coma Scale (GCS) has changed from 15 to 12 is the nurse’s first priority. The GCS is a critical tool used to assess a patient’s level of consciousness, with scores ranging from 3 (deep coma) to 15 (fully awake and alert). A drop in GCS score indicates a significant decline in neurological function, which could be due to increased intracranial pressure, bleeding, or other acute changes in the brain. This requires immediate assessment and intervention to prevent further deterioration.

Choice D Reason:

The client whose deep tendon reflexes have become hyperactive is showing signs of hyperreflexia. Hyperactive reflexes can indicate an upper motor neuron lesion, which affects the descending corticospinal tract. While this is a concerning sign that warrants further investigation, it is not as immediately critical as a sudden change in the GCS score.

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Which sign or symptom would the nurse anticipate in a patient diagnosed with tuberculosis? Select all that apply. One, some, or all responses may be correct.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with Parkinson’s disease (PD) is being discharged home with his wife. To ensure success with the management plan, which discharge action is most effective?

Correct Answer is C

Explanation

The nurse has just received a report on a group of clients on the neurosurgical unit. Which client is the nurse’s first priority?

Correct Answer is C

Explanation

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