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 B
Explanation
A) Eupnea: Eupnea refers to a normal respiratory rate, typically between 12 to 20 breaths per minute for adults. Given that the client’s respiratory rate is significantly lower than this range, documenting the finding as eupnea would not accurately reflect the client’s condition.
B) Bradypnea: Bradypnea is defined as a slower-than-normal respiratory rate, usually less than 12 breaths per minute. With the client's rate at 9 breaths per minute, this is an example of bradypnea. It is crucial for the nurse to document this finding accurately, even though the client denies feeling short of breath, as it could indicate an underlying issue requiring further assessment.
C) Tachypnea: Tachypnea indicates a faster-than-normal respiratory rate, typically over 20 breaths per minute. Since the client's respiratory rate is low at 9 breaths per minute, labeling it as tachypnea would be incorrect and misleading.
D) Dyspnea: Dyspnea refers to difficulty or discomfort in breathing. Although the client does not report feeling short of breath, it is essential to note that the low respiratory rate could still lead to respiratory distress, but it does not meet the criteria for dyspnea based on the client's self-report. Therefore, documenting this finding as dyspnea would not be appropriate.
Correct Answer is B
Explanation
A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.
C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.
D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.