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The nurse is making a home visit to a 70-year-old client with emphysema. Which assessment finding has the most serious implication for this client's nursing care?

1. Increased anterior-posterior diameter of the chest
2. Bilateral crackles throughout the lung fields
3. Pursed-lip breathing
4. Circumoral cyanosis

Explanation

Increased anterior-posterior diameter of the chest, pursed-lip breathing, and circumoral cyanosis are chronic findings in clients with emphysema. They do not indicate acute changes in the client's condition. Bilateral crackles throughout the lung fields indicate excessive pulmonary fluid, requiring acute intervention. The etiology of the fluid excess in the lungs needs to be explored in depth. Recognize that option 2 is the only finding that is considered out of the ordinary in light of the diagnosis.

Contributor

Andrew
Member since: April 2011
(Boynton Beach,FL) Original question source

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Topics: Adult Health: Respiratory, Nursing Process: Assessment

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