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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Constant bubbling in the water seal chamber of a chest drainage system typically indicates an air leak. This can occur if there is a break in the system, allowing air to enter. The air leak could be from the chest tube insertion site, the tubing, or the drainage system itself. Identifying and correcting the source of the air leak is crucial to ensure the system functions properly and the patient’s condition does not worsen.
Choice B Reason:
A tension pneumothorax is a life-threatening condition where air accumulates in the pleural space and cannot escape, leading to increased pressure on the lungs and other thoracic structures. While a tension pneumothorax can cause significant respiratory distress, it is not typically indicated by constant bubbling in the water seal chamber. Instead, signs of tension pneumothorax include tracheal deviation, hypotension, and severe respiratory distress.
Choice C Reason:
A kink in the tubing of a chest drainage system can obstruct the flow of air and fluid, but it does not cause constant bubbling in the water seal chamber. Instead, a kink would likely result in a lack of drainage or intermittent bubbling as the obstruction temporarily blocks and then allows passage of air or fluid.
Choice D Reason:
Increased drainage in a chest tube system indicates that more fluid or air is being removed from the pleural space, but it does not cause constant bubbling in the water seal chamber. Increased drainage might be seen in cases of hemothorax or pleural effusion, where large amounts of fluid are present.
Choice E Reason:
Tidaling refers to the normal rise and fall of water in the water seal chamber with the patient’s respiratory cycle. It indicates that the chest tube is patent and functioning correctly. Absence of tidaling could suggest that the lung has fully re-expanded or that there is an obstruction in the system. However, tidaling itself does not cause constant bubbling.
Correct Answer is F
Explanation
Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication
Choice A Reason:
Assessment: Patient denies vomiting
This choice is not directly related to the effectiveness of Kayexalate. Vomiting can be a symptom of hyperkalemia, but the absence of vomiting does not indicate that the medication is working. Kayexalate works by binding potassium in the intestines and removing it through the stool, so the presence of bowel movements is a more direct indicator of its effectiveness.
Choice B Reason:
ECG: Flattening of QRS complex angle
Flattening of the QRS complex angle is not a typical ECG change associated with hyperkalemia or its treatment. Hyperkalemia typically causes widening of the QRS complex, and effective treatment would normalize this. Therefore, this choice is not correct.
Choice C Reason:
ECG: Widening of the QRS complex
Widening of the QRS complex is a sign of hyperkalemia, not its resolution. If the medication is effective, the QRS complex should return to a normal width. Therefore, this choice is not correct.
Choice D Reason:
Assessment: Patient consumed 60% of meal
While nutritional intake is important, it is not a direct indicator of the effectiveness of Kayexalate. The medication’s effectiveness is better assessed by changes in potassium levels and related symptoms, not by meal consumption.
Choice E Reason:
Assessment: Patient denies nausea
Similar to vomiting, nausea can be a symptom of hyperkalemia, but the absence of nausea does not indicate that the medication is working. The effectiveness of Kayexalate is better assessed by the presence of bowel movements and changes in potassium levels.
Choice F Reason:
Assessment: Patient had 2 semi-formed bowel movements 1 hour after administration of the medication
This is the correct answer. Kayexalate works by binding potassium in the intestines and removing it through the stool. The presence of bowel movements indicates that the medication is working to remove potassium from the body. This is a direct and relevant assessment finding.
Choice G Reason:
ECG: Shortening of P wave duration
Shortening of the P wave duration is not a typical ECG change associated with hyperkalemia or its treatment. Therefore, this choice is not correct.
Choice H Reason:
Assessment: Patient denies pain
Pain is not a typical symptom of hyperkalemia, and its absence does not indicate that the medication is working. Therefore, this choice is not correct.
Choice I Reason:
ECG: Reduction of T wave amplitude
Reduction of T wave amplitude can be a sign of hypokalemia, not hyperkalemia. Effective treatment of hyperkalemia would normalize the T wave amplitude, not reduce it. Therefore, this choice is not correct.
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