Bronchial breath sounds are harsh and high-pitched sounds heard over the trachea or bronchi, and they are not normally heard in healthy lung tissue. The presence of bronchial breath sounds in the right lower lobe suggests consolidation, which refers to the filling of the alveoli with fluid or solid material. This can be caused by conditions such as pneumonia or lung abscess. Therefore, the correct answer is consolidation in her right lower lobe.
When palpating the patient for symmetrical chest movements, if the left side does not move as much as the right side, it indicates that the patient may have left-sided pneumonia or left-sided pneumothorax. Left-sided pneumonia refers to an infection in the left lung, which can cause decreased movement on that side. Left-sided pneumothorax refers to the presence of air in the left pleural space, which can also cause decreased chest movement on the left side. Therefore, the correct answer is 3, 4.
If an infant's chest configuration is the same size in both the AP (anterior-posterior) and lateral dimensions, it indicates a normal chest. This means that there are no abnormalities or deformities present in the chest structure.
When an error is made while charting on a patient, the appropriate action is to place a line through the error, initial it, and then write in the correct information. This ensures that the error is clearly marked and the correct information is recorded. Informing the nurse or supervisor is not necessary in this case as the error can be rectified immediately by the person who made it.
The most likely cause of crepitation in the neck while palpating is an air leak from the lung. This can occur due to a pneumothorax, which is a condition where air accumulates in the pleural space between the lung and the chest wall. The presence of broken ribs in the patient suggests the possibility of a traumatic injury to the chest, which could lead to a pneumothorax. The air leak from the lung can cause subcutaneous emphysema, leading to the crepitation felt in the neck. This is a common finding in patients with chest trauma and can be a potentially serious condition requiring immediate medical attention.
Based on the signs and symptoms observed in the patient, such as high fever, diaphoresis (excessive sweating), increased respiratory rate, use of accessory muscles for breathing, and palpable rhonchi (abnormal sounds) in the right lower lobe, the most likely diagnosis would be bacterial pneumonia. Bacterial pneumonia is an infection of the lungs caused by bacteria, which can lead to symptoms such as high fever, difficulty breathing, and abnormal lung sounds. Heart attack and pneumothorax may present with different symptoms, while viral pneumonia may have similar symptoms but is less likely given the severity of the patient's presentation.
The question is asking about a symptom called orthopnea, which is shortness of breath that occurs when lying flat. The correct answer is "Do you need to use extra pillows behind your head and back to keep from getting short of breath when you sleep?" This question specifically addresses the symptom of orthopnea by asking if the patient needs to elevate their head and back with extra pillows to prevent shortness of breath while sleeping. This can help determine if the patient experiences orthopnea.
Diminished breath sounds and a shift in the trachea to the affected side are indicative of atelectasis, which is the collapse or closure of a lung or part of a lung. In this case, the patient's symptoms suggest right-sided atelectasis, as the breath sounds are diminished in the right lower lobe and the trachea is shifted to the right. Atelectasis can be caused by various factors, such as blockage of the airway, compression of the lung, or surfactant deficiency.
To help determine a patient's level of consciousness, it is important to ask questions that assess their orientation to person, place, and time. Question 2, "Can I see your identification wristband?" helps determine if the patient is aware of their own identity and location. Question 4, "How are you feeling today?" helps assess the patient's awareness of their current state and overall well-being. These questions provide valuable information about the patient's cognitive function and level of consciousness.
The patient's change in behavior, specifically becoming argumentative and making threats, suggests that there may be underlying emotional issues at play. It is important to consider the patient's emotional state in order to understand and address their behavior. This could be a result of fear, anxiety, or frustration related to the cancer diagnosis. Evaluating the patient's emotional state can help healthcare providers provide appropriate support and interventions to address their emotional needs.
Given the scenario where the drug dosage is outside the normal department guidelines, it is important to ensure patient safety. Contacting the physician to confirm the order is the appropriate course of action as it allows for clarification and verification of the dosage. This step helps to prevent any potential harm to the patient and ensures that the medication is administered correctly.
