During assessment of the patient admitted to the hospital for dehydration, the nurse notes that he has a barrel chest. Understanding this assessment finding, the nurse asks the patient if he has a history of:
A) Emphysema
B) Asthma
C) Chronic bronchitis
D) Pneumonia
Ans: A
Feedback: Barrel chest occurs as a result of overinflation of the lungs. In a patient with emphysema, the ribs are more widely spaced, and the intercostal spaces tend to bulge on expiration.
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The nurse is working in a long-term care facility. As clients are assessed, the nurse notes that one client is confused and incontinent, which is new behavior for the client. The nurse should further assess the client, suspecting:
1. the client has had a stroke. 2. the client's oxygen level is decreased. 3. the client has cystitis. 4. the client has kidney stones.
Your 6-year-old patient's respiratory rate is 36 breaths per minute, which you record as
a. within normal limits for his age. c. hyperpnea. b. tachypnea. d. hyperventilation.
A nurse is preparing an education program on safety concerns for elderly adults living in their own homes. To address the sensory changes in this age group, what should the nurse recommend to this group?
1. Have carbon monoxide detectors that are checked on a scheduled basis. 2. Place a list of emergency numbers near the phone. 3. Install telephones that use a blinking light instead of a ringer. 4. Ask someone to do their cooking for them.
A female client has been admitted to an inpatient psychiatric facility with a diagnosis of posttraumatic stress disorder after a history of violence by her boyfriend. During the initial assessment interview, which assessment would be the priority?
A) Nutritional status B) Hydration status C) Sleep patterns D) Suicide risk