Which finding would be of MOST concern when the nurse assesses a client with emphysema (COPD)?
barrel chest
respiratory rate of 22 per minute
Oral cyanosis
decreased lung sounds on expiration
Pursed-lip expiration
The Correct Answer is C
A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.
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Correct Answer is A
Explanation
A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.
Correct Answer is B
Explanation
A. Poor electrical impulse conduction may lead to arrhythmias but does not cause a murmur.
B. A heart murmur is caused by turbulent blood flow, often through narrowed or leaking valves, creating an abnormal heart sound.
C. Left ventricular enlargement can contribute to other cardiac issues but does not directly cause murmurs.
D. Weak atrial contractions may lead to decreased cardiac output but not necessarily to a murmur.
E. While hypertension can affect the heart, it is not the direct cause of a murmur.