The nurse is performing an integumentary system assessment of a patient who has smoked for the last 40 years. The patient has clubbing of the fingernails. What does this finding indicate to the nurse?
The patient has asthma.
The patient has cardiovascular disease.
The patient has emphysema.
The patient has chronic hypoxemia.
The Correct Answer is D
A) The patient has asthma: While asthma can lead to respiratory symptoms and issues, it is not typically associated with clubbing of the fingernails. Asthma primarily affects airway constriction and inflammation, rather than causing the long-term changes in nail morphology seen with clubbing.
B) The patient has cardiovascular disease: Although some cardiovascular conditions can lead to clubbing, it is more commonly associated with chronic lung diseases. Cardiovascular disease might cause other signs or symptoms, but clubbing alone is not a definitive indicator of this condition.
C) The patient has emphysema: Emphysema, a type of chronic obstructive pulmonary disease (COPD), is characterized by the destruction of lung tissue and impaired airflow. While it can contribute to hypoxemia, clubbing is not a common finding specifically associated with emphysema.
D) The patient has chronic hypoxemia: Clubbing of the fingernails is a classic sign of chronic hypoxemia, often resulting from long-term respiratory conditions like COPD, interstitial lung disease, or lung cancer. It indicates a prolonged lack of oxygen in the blood, leading to changes in the nail bed and digit shape. Given the patient's long smoking history, chronic hypoxemia is the most likely explanation for this finding.
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Correct Answer is C
Explanation
A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.
B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.
C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.
D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.
Correct Answer is B
Explanation
A) "Attempt to rotate your head in a circular manner": This instruction is focused on rotation rather than lateral flexion. While rotation assesses different neck movements, it does not specifically evaluate lateral flexion.
B) "Lean your head to the side and attempt to touch your ear to your shoulder": This instruction directly assesses lateral flexion of the neck. It encourages the client to bend their head to the side, effectively demonstrating the range of motion in that direction.
C) "Attempt to raise your shoulders up toward your ears": This instruction assesses shoulder elevation and shrugging rather than lateral flexion of the neck. It does not provide information about the lateral movement of the head.
D) "Tilt your head back and look at the ceiling": This instruction assesses extension of the neck rather than lateral flexion. It evaluates the ability to move the head backward.