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 C
Explanation
A. The closure of the pulmonic and mitral valves corresponds to heart sound S1, not S2.
B. The tricuspid and mitral valves close with S1.
C. Heart sound S2 represents the closure of the aortic and pulmonic valves, signaling the end of systole and the beginning of diastole.
D. The mitral valve closes with S1, not S2.
E. The pulmonic and tricuspid valves do not correspond with S2.
Correct Answer is ["A","B","E"]
Explanation
A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.