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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View Related questions
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. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.