A nurse is assessing a client with a history of chronic obstructive pulmonary disease (COPD). Which of the following findings is most concerning?
The client has a respiratory rate of 22 breaths per minute.
The client has a temperature of 38°C (100.4°F).
The client has a pulse oximetry reading of 88%.
The client has a blood pressure of 140/90 mmHg.
The Correct Answer is C
Choice A rationale
A respiratory rate of 22 breaths per minute is slightly elevated but not necessarily concerning for a client with COPD. COPD patients often have higher respiratory rates due to their chronic lung condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which could be a sign of infection. However, it is not the most concerning finding in a COPD patient.
Choice C rationale
A pulse oximetry reading of 88% is concerning because it indicates hypoxemia. COPD patients often have lower oxygen levels, but a reading below 90% is worrisome and may require supplemental oxygen or other interventions.
Choice D rationale
A blood pressure of 140/90 mmHg is elevated but not immediately concerning in the context of COPD. It is important to monitor, but it is not the most critical finding.
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Correct Answer is A
Explanation
Choice A rationale
Hypersplenism is a condition often associated with cirrhosis, where the spleen becomes overactive. This leads to the destruction of blood cells, causing anemia (low red blood cells), leukopenia (low white blood cells), and thrombocytopenia (low platelets).
Choice B rationale
Peptic ulcer disease primarily affects the stomach and duodenum, leading to ulcers and bleeding. It does not typically cause anemia, leukopenia, and thrombocytopenia in the context of cirrhosis.
Choice C rationale
Cholecystitis is the inflammation of the gallbladder, usually due to gallstones. It does not cause the blood cell abnormalities seen in cirrhosis.
Choice D rationale
Esophageal varices are swollen veins in the esophagus that develop due to portal hypertension in cirrhosis. While they can cause bleeding, they do not directly cause anemia, leukopenia, and thrombocytopenia.
Correct Answer is D
Explanation
Choice A rationale
Poor blood glucose control is a significant factor in delayed wound healing in patients with diabetes. Hyperglycemia impairs various aspects of the immune response, reduces blood flow, and increases the risk of infection, all of which contribute to delayed healing.
Choice B rationale
Inadequate protein intake can also contribute to delayed wound healing. Protein is essential for the repair and regeneration of tissues, and a deficiency can impair the body’s ability to heal wounds effectively.
Choice C rationale
Peripheral neuropathy, a common complication of diabetes, can lead to decreased sensation in the feet, making it more likely for injuries to go unnoticed and untreated. This can result in chronic wounds and delayed healing.
Choice D rationale
All of the above factors—poor blood glucose control, inadequate protein intake, and peripheral neuropathy—can contribute to delayed healing of foot ulcers in patients with diabetes. Each of these factors plays a role in the complex process of wound healing and can hinder the body’s ability to repair itself.