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?
Respiratory rate of 20
Vesicular sounds heard in the lung periphery
Capillary refill time of 5 seconds
AP diameter of 1:2
Equal chest expansion
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. In asthma, increased airway resistance can lead to decreased fremitus due to air trapping and poor conduction of vibrations.
B. Emphysema results in hyperinflated lungs, which typically decreases tactile fremitus because of increased air in the alveoli.
C. Pneumothorax involves air in the pleural space, leading to decreased tactile fremitus as well, since air does not conduct vibrations well.
D. Acute bronchitis can cause some changes in fremitus, but it typically does not significantly increase it.
E. Pneumonia causes consolidation of lung tissue, which increases tactile fremitus due to enhanced transmission of vibrations through solidified lung tissue.
Correct Answer is ["A","D"]
Explanation
A. Asking about shortness of breath is critical subjective data that indicates respiratory distress.
B. Palpating for masses is more of a physical assessment and does not yield subjective data.
C. Inspecting skin and nails is also part of the objective assessment rather than subjective data.
D. Inquiring about the color and quantity of sputum provides important subjective data related to respiratory function.
E. Auscultation is an objective assessment technique and does not pertain to subjective data.