A nurse in an emergency department (ED) is admitting a client.
Vital Signs
1000:
Temperature 38.6° C (101.5° F)
Heart rate 106/min
Respiratory rate 26/min
Blood pressure 110/54 mm Hg
Oxygen saturation 94% on room air
Nurses Notes
1000:
Client presents to ED with report of shortness of breath for 3 days, with headache, chills, fever, sore throat, and cough.
Oriented to person, place, and time. Appears lethargic, difficulty answering questioning due to shortness of breath. Follows simple commands, moves all extremities with weakness.
Client's face is flushed, sinus tachycardia, rate of 106/min, $152 heart sounds heard on auscultation. Pulses palpable.
Breath sounds with crackles to right lower lobe, tachypnea, rate of 26/min. Tactile fremitus and decreased lung expansion noted upon assessment. Frequent productive cough with thick yellow sputum. Client denies hemoptysis. Unable to lie down, states they are "more comfortable sitting up."
Bowel sounds active x 4 quadrants. Denies diarrhea, last bowel movement yesterday. States "no appetite since I've been sick."
Reports decreased urination in the past day.
Client reports they have not had a pneumococcal vaccine. States, "1 Just hate needles."
Diagnostic Results
1030:
Chest x-ray.
Areas of increased density and white infiltrates to lower right lobe.
Select 3 objective findings in the client's medical record that may be indicative of pneumonia.
decreased urine output
headache
respiratory assessment
Chest X-ray
Religion
Bowel sounds
perception of needles
Correct Answer : A,C,D
A. Decreased urine output: While not a direct sign of pneumonia, decreased urine output can be an objective finding indicative of dehydration, which often accompanies infections like pneumonia.
B. Headache: Although the client has a headache, it is a subjective symptom rather than an objective finding and is not a primary indicator of pneumonia.
C. Respiratory assessment: The respiratory assessment reveals shortness of breath, crackles in the right lower lobe, and tachypnea, which are commonly associated with pneumonia.
D. Chest X-ray: The chest X-ray shows areas of increased density and infiltrates in the right lower lobe, a hallmark finding that indicates pneumonia.
E. Religion: This does not relate to the clinical findings associated with pneumonia.
F. Bowel sounds: Normal bowel sounds are not indicative of pneumonia.
G. Perception of needles: This is irrelevant to the diagnosis of pneumonia.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
A. The right upper quadrant is typically associated with gallbladder or liver issues, not duodenal ulcers.
B. The right lower quadrant is primarily associated with appendicitis or other conditions involving the appendix.
C. The left upper quadrant is where the duodenum is located, making it the appropriate area to assess for pain related to a duodenal ulcer.
D. The left lower quadrant is often associated with conditions affecting the sigmoid colon or left ovary but not typically with duodenal ulcers.
Correct Answer is B
Explanation
A. The palm is not the best part of the hand to assess lymph nodes, as it lacks the sensitivity needed for palpation.
B. The parts of the fingers, particularly the pads of the fingers, are used to assess lymph node size. This allows for a more precise and sensitive examination of the lymph nodes.
C. The dorsal side of the hand is not typically used for palpation because it is less sensitive.
D. The ulnar surface of the hand is not commonly used for this purpose, as the fingertips provide better tactile sensation for assessing lymph node size.