A nurse is assessing a client who has pulmonary edema. Which of the following findings should the nurse expect?
Bradycardia
Wheezing
Pale, Dry Skin
Pink, frothy sputum
The Correct Answer is D
Rationale:
A. Bradycardia is not typically associated with pulmonary edema; instead, tachycardia is more common as the body tries to compensate for decreased oxygenation.
B. Wheezing may occur in certain respiratory conditions but is not a classic finding in pulmonary edema; instead, crackles or rales are more expected due to fluid accumulation.
C. Pale, dry skin is not characteristic of pulmonary edema; the client may present with cyanosis or clammy skin due to hypoxia.
D. Pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the alveoli and is often associated with acute heart failure.
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Correct Answer is D
Explanation
Rationale:
A. Decreased heart rate is not typical; children with Kawasaki disease often experience tachycardia.
B. Peeling of the soles of the feet is more commonly observed in the convalescent phase of Kawasaki disease rather than the acute phase.
C. Pain in weight-bearing joints can occur in Kawasaki disease but is not the hallmark symptom during the acute phase.
D. Fever unresponsive to antipyretics is a classic finding in the acute phase of Kawasaki disease, indicating ongoing inflammation and a need for further intervention.
Correct Answer is D
Explanation
Rationale:
A. Speaking loudly in a high-pitched voice is not effective for individuals with sensorineural hearing loss, as they may struggle with high-frequency sounds.
B. Asking the client's partner to choose their meal removes the client's autonomy and does not facilitate direct communication.
C. While expecting extended time for verbal responses is considerate, it does not provide a practical solution for meal selection.
D. Asking the client to point to items on a picture menu is an effective way to facilitate communication, allowing the client to express their preferences without relying on verbal communication alone.