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The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

A.

Respiratory rate of 20

B.

Vesicular sounds heard in the lung periphery

C.

Capillary refill time of 5 seconds

D.

AP diameter of 1:2

E.

Equal chest expansion

Answer and Explanation

The Correct Answer is C

A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.

 

B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.

 

C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.

 

D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.

 

E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.


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View Related questions

Correct Answer is E

Explanation

A. Cutaneous pain refers to pain from the skin and subcutaneous tissues, which is not described here.

B. Parasympathetic pain is not a recognized category of pain.

C. Visceral pain arises from internal organs and does not typically present as sharp, tingling, or numb.

D. Deep somatic pain is related to muscles, joints, and bones and typically does not have the sharp, tingling quality described.

E. Neuropathic pain is characterized by sharp, tingling sensations and numbness, often resulting from nerve damage, which fits the client's description.

Correct Answer is A

Explanation

A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.

B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.

C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.

D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.

E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.

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