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A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client?
- A. Fine crackles in the lungs
- B. Increased anteroposterior diameter of the chest
- C. Increased tactile fremitus
- D. Fever and chills
Correct Answer: B
Rationale: The correct answer is B: Increased anteroposterior diameter of the chest. In COPD with emphysema, there is air trapping leading to hyperinflation of the lungs, causing the chest to expand more in the front-to-back direction (increased anteroposterior diameter). This is known as barrel chest.
A: Fine crackles are not typically associated with COPD/emphysema, they are more common in conditions like heart failure or pneumonia.
C: Increased tactile fremitus is not typically seen in COPD/emphysema, it may be present in conditions like pneumonia.
D: Fever and chills are not typical findings in COPD/emphysema unless there is an infection present.
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A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?
- A. Different apical and radial pulses.
- B. Shortness of breath on exertion.
- C. Excessive sweating.
- D. Systolic blood pressure of 150 mm Hg.
Correct Answer: A
Rationale: The correct answer is A: Different apical and radial pulses. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to irregular heartbeat and pulse. This results in a discrepancy between the apical (heard by auscultation) and radial (felt at the wrist) pulses. Shortness of breath on exertion (B), excessive sweating (C), and systolic blood pressure of 150 mm Hg (D) are not specific to atrial fibrillation and can occur in various conditions.
A nurse is teaching a client about the causes of osteoporosis. The nurse should include which of the following types of medication therapy as a risk factor for osteoporosis?
- A. Thyroid hormones
- B. Antihypertensives
- C. Steroids
- D. Insulin
Correct Answer: C
Rationale: The correct answer is C: Steroids. Steroids, specifically glucocorticoids, are known to increase the risk of osteoporosis by decreasing bone formation and increasing bone resorption. Long-term use of steroids can lead to bone loss, making individuals more susceptible to fractures. Thyroid hormones (A) do not directly cause osteoporosis. Antihypertensives (B) and insulin (D) are not associated with increased risk of osteoporosis.
A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?
- A. Low blood pressure
- B. Elevated central venous pressure (CVP).
- C. Decreased urine output
- D. Increased lung crackles
Correct Answer: B
Rationale: The correct answer is B: Elevated central venous pressure (CVP). In right-sided heart failure, the right ventricle fails to effectively pump blood to the lungs, causing blood to back up in the systemic circulation. This leads to increased pressure in the venous system, including the central veins. Elevated CVP is a classic sign of right-sided heart failure. Low blood pressure (A) is more commonly associated with left-sided heart failure. Decreased urine output (C) may occur due to poor perfusion but is not specific to right-sided heart failure. Increased lung crackles (D) are typically seen in left-sided heart failure, not right-sided heart failure.
A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
- A. Do not apply heat to the area of irradiation.
- B. Use sunscreen on the irradiated area.
- C. Apply lotion generously to the irradiated area.
- D. Rub the area with an alcohol-based lotion.
Correct Answer: A
Rationale: Correct Answer: A. Do not apply heat to the area of irradiation.
Rationale: Heat can increase skin sensitivity and damage during radiation therapy. It is important to avoid any source of heat on the irradiated area to prevent further skin irritation and burns.
Summary:
B. Using sunscreen is not necessary for radiation therapy as it does not protect against radiation.
C. Applying lotion generously can interfere with the radiation treatment and cause skin irritation.
D. Rubbing the area with an alcohol-based lotion can further irritate the skin and is not recommended during radiation therapy.
A nurse is providing teaching to a client who has hypertension and a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse provide?
- A. Take the medication early in the day.
- B. Take the medication at bedtime.
- C. Take the medication with food.
- D. Take the medication only when blood pressure is high.
Correct Answer: A
Rationale: The correct answer is A: Take the medication early in the day. Hydrochlorothiazide is a diuretic that increases urine production, which can cause frequent urination. Taking it early helps prevent nighttime urination, promoting better sleep. Taking it with food may reduce gastrointestinal upset. Taking it only when blood pressure is high is incorrect, as it should be taken regularly to maintain consistent blood pressure control. Bedtime dosing may lead to nocturnal diuresis and disturb sleep. The other choices are irrelevant or incorrect in the context of hydrochlorothiazide administration.