Nokea
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease?
- A. Cough and dyspnea
- B. Black-streaked sputum
- C. Tenacious secretions
- D. Barrel chest
Correct Answer: B
Rationale: A functional assessment provides data on the lifestyle, living environment, and work environment of the client, which can contribute to lung disorders. A black-tinged sputum is suggestive of prolonged exposure to coal dust. Cough, dyspnea, and tenacious secretions are vague respiratory symptoms that are not specific to occupational lung disease. The presence of barrel chest is indicative of trapped oxygen in the lungs over a prolonged period of time.
You may also like to solve these questions
The nurse is caring for a client with tension pneumothorax. Which nursing assessment would alert the nurse to the development of a mediastinal shift in this client?
- A. Fluctuation of the fluid in the water-seal chamber
- B. Shift of rib cage toward affected side
- C. Sucking sound heard on inspiration and expiration
- D. Shift of trachea, esophagus, heart, and great vessels
Correct Answer: D
Rationale: In a tension pneumothorax, the air is sucked into the pleural cavity and cannot escape. The air accumulates and pushes the trachea, esophagus, heart, and great vessels toward the unaffected side. Fluctuation of the fluid in the water-seal chamber is an expected finding. There may be a paradoxical movement of the ribs but not a shifting to the side. A sucking sound may be heard with a pneumothorax, but air moves in and cannot escape out.
A client admitted for the treatment of venous thromboembolism reports chest pain and dyspnea. Which of the following is the primary intervention for the nurse to implement?
- A. Apply oxygen, as prescribed
- B. Assess and rate the chest pain
- C. Apply compression stockings
- D. Prepare for ventilation-perfusion scan
Correct Answer: A
Rationale: Based on the client's symptoms, the nurse suspects pulmonary embolism (PE). Emergency intervention is required to decrease the client's risk for death; therefore, the priority intervention is the application of oxygen. Although managing the client's pain is important this is not the priority intervention. The client may be prescribed a ventilation-perfusion scan and pulmonary angiography but these actions are not the priority interventions by the nurse. Application of compression stockings is ideal for preventing pulmonary emboli in high-risk clients but not an appropriate intervention after occurrence.
The nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer?
- A. Mucopurulent sputum
- B. Pain on inspiration
- C. Obvious trauma
- D. Shortness of breath
Correct Answer: A
Rationale: For a client with lung cancer, a cough productive of mucopurulent or blood-streaked sputum is a cardinal sign of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders but are not considered indicative of lung cancer.
The nurse is preparing a client for emergency thoracic surgery. What would the nurse document in the assessment?
- A. Emergency contacts
- B. IV fluids ordered
- C. General statement of the client's condition
- D. Detailed physical assessment
Correct Answer: C
Rationale: If the surgery is an emergency, physical assessment may be limited to a general statement of the client's condition, a list of emergency measures and treatments done, and vital signs. The nurse would not document emergency contacts or a detailed physical assessment. The nurse would document the IV fluids running and not any that are ordered.
What are the condition(s) that make up Virchow's triad? Select all that apply.
- A. Hypercoagulability
- B. Disruption of the vessel lining
- C. Hypocoagulability
- D. Edema
- E. Venostasis
Correct Answer: A,B,E
Rationale: Three conditions, referred to as Virchow's triad, predispose a person to clot formation: venostasis, disruption of the vessel lining, and hypercoagulability. Edema plays no part in Virchow's triad.