Pathophysiology chapter 30 respiratory tract infections, neoplasms, and childhood disorders

The nurse is assessing several clients in an outpatient clinic. Which client is most likely to have chronic histoplasmosis?

A 52-year old male with chronic obstructive lung disease who smokes Explanation: Chronic histoplasmosis is more common in middle-aged men who smoke and in people with chronic lung disease. p 792

A nurse runs into an old high school friend after 20 years and notes her friend continues to smoke. The friend asks, "Do you think I sound hoarse?" Which assessment findings leads the nurse to suspect her friend has developed cancer? Select all that apply.

"I seem to have some difficulty swallowing food. This is new for me." "Can you feel how large my lymph nodes are on my neck and armpits (axillae)?" Explanation: Tumors that invade the mediastinum may cause hoarseness because of the involvement of the recurrent laryngeal nerve and cause difficulty in swallowing because of compression of the esophagus. An uncommon complication called superior vena cava syndrome occurs in some persons with mediastinal involvement. Interruption of blood flow in this vessel usually results from compression by the tumor or involved lymph nodes. Urinary incontinence, pericardial friction rub, and subcutaneous emphysema are not related to this cancer but can occur as complications from treatments. p 796

While educating a smoking cessation class, a client asks the nurse, "If I can still get lung cancer, what should I be looking for?" Which response by the nurse is best?

"The earliest symptoms relate to a chronic cough and shortness of breath." Explanation: The earliest symptoms usually are chronic cough, shortness of breath, and wheezing because of airway irritation and obstruction. Hemoptysis (i.e., blood in the sputum) occurs when the lesion erodes into blood vessels. Later symptoms include coughing up blood, extreme fatigue, and weight loss. p 796

The nurse has administered a Mantoux (tuberculin) test to four clients. Select the client who will most likely have a suppressed response.

A client diagnosed with human immunodeficiency virus (HIV) Explanation: Because the hypersensitivity response to the tuberculin test depends on cell-mediated immunity, false-negative test results can occur because of immunodeficiency states that result from HIV infection, immunosuppressive therapy, lymphoreticular malignancies, or aging. This is called anergy. In the immunocompromised person, a negative tuberculin test result can mean that the person has a true lack of exposure to tuberculosis or is unable to mount an immune response to the test. p 790

Which clients would be considered at high risk for developing pneumonia (both community and hospital setting)? Select all that apply.

A young adult in motorcycle accident with head injury requiring tracheostomy and mechanical ventilation A HIV-positive client with a WBC count of 2000 who has been camping near a commercial farm raising chickens for food A school-aged child with severe asthma controlled by steroids admitted for an exacerbation Explanation: Persons requiring intubation and mechanical ventilation are particularly at risk, as are those with compromised immune function, chronic lung disease (like asthma), and airway instrumentation, such as endotracheal intubation or tracheotomy. Ventilator-associated pneumonia is pneumonia that develops in mechanically ventilated clients more than 48 hours after intubation. Neutropenia and impaired granulocyte function predispose to infections caused by S. aureus, Aspergillus, gram-negative bacilli, and Candida. Pneumonia in immunocompromised persons remains a major source of morbidity and mortality. The epithelial cells of critically and chronically ill persons are more receptive to binding microorganisms that cause pneumonia. p 785

An adult comes to the urgent care clinic reporting facial pain, headache, and copious amounts of thick purulent nasal discharge. Based on these symptoms, the nurse practitioner suspects the client is experiencing which condition?

Acute viral rhinosinusitis Explanation: The symptoms of acute viral rhinosinusitis often are similar to those of the common cold and allergic rhinitis. They include facial pain, headache, purulent nasal discharge, decreased sense of smell, and fever. The discharge from a common cold is clear and watery; ear pain is the primary symptom with a blocked Eustachian tube. Mastoiditis is swelling on one side of the neck. p 782

A client has developed community-acquired pneumonia and is being treated at home. What does the nurse recognize are the methods in the diagnosis of community-acquired pneumonia? Select all that apply.

Age Coexisting health problems Severity of illness Explanation: The methods used in the diagnosis of community-acquired pneumonia depends on age, coexisting health problems, and the severity of illness. In people younger than 65 years of age and without coexisting disease, diagnosis is usually based on history and physical examination, chest radiographs, and knowledge of the microorganisms currently causing infections in the community. Sputum specimens may be obtained for staining procedures and cultures. Blood cultures may be done for people requiring hospitalization. p 785

A client with a history of chronic obstructive pulmonary disease (COPD) has developed influenza. Which statements about possible treatments are accurate for this client? Select all that apply.

At the onset of influenza-like symptoms, antiviral medications should be initiated within the first 48 hours. The antiviral drug of choice is oral oseltamivir. Explanation: Two antiviral drugs are available for treatment of influenzas: Zanamivir and oseltamivir are inhibitors of neuraminidase, the glycoprotein necessary for viral replication and release. These drugs, which have been approved for treatment of acute uncomplicated influenza infection, are effective against both influenza A and B viruses. Zanamivir is administered intranasally and oseltamivir is administered orally. Zanamivir can cause bronchospasm and is not recommended for persons with asthma or chronic obstructive lung disease. To be effective, the antiviral drugs should be initiated within 48 hours after onset of symptoms. p 782

An infant who was born prematurely and developed respiratory distress syndrome was placed on mechanical ventilation for several weeks. What condition should the nurse monitor the infant for related to the long-term ventilatory support?

Bronchopulmonary dysplasia Explanation: Bronchopulmonary dysplasia (BPD) is a chronic lung disease that develops in premature infants who were treated with long-term mechanical ventilation, mainly for RDS. The condition is considered to be present if the neonate is oxygen dependent at 36 weeks after gestation. p 801

An infant born 10 weeks premature was placed on mechanical ventilation. Eight weeks later a nursing assessment reveals a barrel chest, tachycardia, rapid and shallow breathing, hypoxemia, hypercapnia, and poor weight gain. Based on this assessment, which diagnosis is most likely?

Bronchopulmonary dysplasia Explanation: Bronchopulmonary dysplasia (BPD) is a chronic lung disease that develops in premature infants who were treated with long-term mechanical ventilation. High-inspired oxygen concentration and injury from positive-pressure ventilation have been implicated. BPD is characterized by chronic respiratory distress, persistent hypoxemia when breathing room air, reduced lung compliance, increased airway resistance, and severe expiratory flow limitation. The infant with BPD often demonstrates a barrel chest, tachycardia, rapid and shallow breathing, chest retractions, cough, and poor weight gain. p801

A middle-aged client with a 30-year history of smoking was diagnosed with lung cancer. A health history revealed previous exposure to air pollution, asbestos, and radiation. Which factor most likely had the greatest impact on development of the lung cancer?

Cigarette smoke Explanation: Cigarette smoking causes more than 80% of cases of lung cancer. The risk for lung cancer among cigarette smokers increases with duration of smoking and the number of cigarettes smoked per day. Cigarette smokers can benefit at any age from smoking cessation. Industrial hazards also contribute to the incidence of lung cancer. A commonly recognized hazard is exposure to asbestos. The mean risk for lung cancer is significantly greater in asbestos workers compared to the general population. In addition, tobacco smoke contributes heavily to the development of lung cancer in people exposed to asbestos. p 794

A 3-year-old boy has been diagnosed with croup (acute laryngotracheobronchitis). The nurse anticipates the plan of care to include:

Cool, humidified air to relieve airway spasms Explanation: Acute laryngotracheobronchitis (viral croup) is best treated with cool, humidified air. Chest physiotherapy would not be beneficial because there are no secretions to remove and medications would not be required. p 801

A client presents with atypical pneumonia signs/symptoms and is diagnosed with Mycoplasma pneumonia. For which characteristics of the cough should the nurse assess this client? Select all that apply.

Dry Hacking Nonproductive Explanation: Cough, when present (in clients with Mycoplasma pneumoniae), is characteristically dry, hacking, and nonproductive. It is not moist or fulminating. p 785

A client is preparing to travel for business and has developed the common cold. The client informs the nurse that she will be flying and does not want to give it to anyone else. When should the nurse inform the client is the most highly contagious period?

During the first 3 days after the onset of symptoms Explanation: The most highly contagious period is during the first 3 days after the onset of symptoms, and the incubation period is approximately 5 days. p 780

Which acute respiratory infection in children poses the greatest threat of severe hypoxia caused by inflammatory edema?

Epiglottitis Explanation: Among the respiratory tract infections that affect small children are croup, epiglottitis, and bronchiolitis. Croup or acute laryngotracheobronchitis is a viral infection that affects the larynx, trachea, and bronchi. Epiglottitis is a life-threatening supraglottic infection with inflammatory edema and possible airway obstruction. Acute bronchiolitis is a viral infection of the lower airways, most commonly caused by the respiratory syncytial virus. Asthma is a reactive airway disease rather than an infection. p 802

A parent calls 911 and states her child is having trouble breathing. The child is rushed to the emergency department. Upon assessment, the child appears pale, toxic, and lethargic and assumes a distinctive position—sitting up with the mouth open and the chin thrust forward. The parent states that the child just developed a sore throat and fever today. The health care provider determines that the child is experiencing:

Epiglottitis Explanation: Epiglottitis typically presents with an acute onset of sore throat and fever. The child appears pale, toxic, and lethargic and assumes a distinctive position-sitting up with the mouth open and the chin thrust forward. Symptoms rapidly progress to difficulty swallowing, a muffled voice, drooling, and extreme anxiety. Moderate to severe respiratory distress is evident. The other options do not have these manifestations. p 802

The "cold viruses" are rapidly spread from person to person. Which is considered the greatest source of spread of the cold virus?

Fingers Explanation: Cold viruses have been found to survive for more than 5 hours on the skin and hard surfaces, such as plastic countertops. Aerosol spread of colds through coughing and sneezing is much less important than the spread by fingers picking up the virus from contaminated surfaces and carrying it to the nasal membranes and eyes. The fingers are the greatest source of spread, and the nasal mucosa and conjunctival surface of the eyes are the most common portals of entry of the virus. p 780

A nurse is assessing a 2-week-old infant with pulmonary edema. Which symptom indicates the infant is experiencing respiratory distress?

Grunting during expiration Explanation: Children with restrictive lung disorders, such as pulmonary edema or RDS, breathe at faster rates, and their respiratory excursions are shallow. Grunting is an audible noise emitted during expiration. An expiratory grunt is common as the child tries to raise the end-expiratory pressure and thus prolong the period of oxygen and carbon dioxide exchange across the alveolar-capillary membrane. p 799

The community health nurse is developing a program to decrease the amount of pulmonary tuberculosis that has recently risen in her area. Which populations at risk will the nurse target? Select all that apply.

HIV-infected people Foreign-born people from countries with a high incidence of tuberculosis Residents of high-risk congregate settings p 788

The nurse in a hospital is caring for a child with respiratory distress. What oxygen delivery method would be appropriate for the child when the oxygen saturation consistently falls below 90%?

High-flow oxygen via nasal cannula Explanation: Treatment is supportive and includes administration of supplemental oxygen if the oxygen saturation consistently falls below 90%. Evidence suggests that children with respiratory distress needing oxygen should first be given high-flow oxygen via a nasal cannula since it tends to increase oxygen saturation, increase comfort, and increase the overall respiratory condition. p 803

What diagnostic test does the nurse explain to the client will assist with the diagnosis of disseminated histoplasmosis?

Histoplasma urine antigen assay Explanation: The type of test that is used depends on the type of involvement that is present. In pulmonary disease, sputum cultures are rarely positive, whereas blood or bone marrow cultures from immunocompromised people with acute disseminated disease are positive in 80% to 90% of cases. Some people may need a surgical biopsy on their suspicious lung nodule to rule out malignancy. Antigen tests can be performed on blood, urine, cerebrospinal fluid, or bronchoalveolar lavage fluid. A histoplasma urine antigen assay is particularly useful in detecting disseminated histoplasmosis. p 792

A client has been diagnosed with an advanced tumor that has invaded the mediastinum. The client would most likely manifest:

Hoarseness and difficulty swallowing Explanation: Tumors that invade the mediastinum cause hoarseness, difficulty in swallowing, and retrosternal pain. Hemoptysis may occur but is not specific to mediastinal involvement. p 780

What is the underlying cause of respiratory failure in a child with bronchiolitis?

Impaired gas exchange Explanation: The child with bronchiolitis is at risk for respiratory failure resulting from impaired gas exchange. p 803

The nurse is assessing a client who states he felt fine all day and then, within 5 minutes, began to feel extremely weak and tired and began having a fever. What do these symptoms indicate that the client may be experiencing?

Influenza Explanation: One distinguishing feature of an influenza viral infection is the rapid onset, sometimes in as little as 1 to 2 minutes, of profound malaise. Viral pneumonia is a complication of influenza. Reye syndrome is a complication of influenza that is extremely rare and is found mostly in children after being give aspirin as an antipyretic. The common cold has more of a slow onset. p 783

A nurse is assessing a 1-year-old child diagnosed with croup. Which manifestation would most likely be present?

Inspiratory stridor and barking cough Explanation: Croup is characterized by inspiratory stridor, hoarseness, and a barking cough. p 802

A 66-year-old man presents in the emergency room accompanied by his wife, who claims that he has been acting confused. The man reports a sudden onset of severe weakness and malaise and has a dry cough and diarrhea. His temperature is 39.3°C, and his blood work indicates his sodium level is at 126 mEq/L (126 mmol/L). The normal level is 135-145 mEq/L (135 to 145 mmol/L). What will be the assessing physician's most likely suspicion?

Legionnaire disease Explanation: Confusion, dry cough, diarrhea, and hyponatremia are associated with Legionnaire disease but less so with bronchopneumonia, mycoplasma pneumonia, and pneumococcal pneumonia. p 788

Most respiratory disorders in infants make it difficult to get air into their lungs. This is due to a decrease in which factor?

Lung compliance Explanation: Most respiratory disorders in infants produce a decrease in lung compliance or an increase airway resistance. Therefore, it takes more effort to inflate the lungs. Respiratory disorders increase the cellular demand for oxygen because the alveolar-capillary membrane is often impaired by the disease process. A compensatory tachypnea is an attempt to deliver more oxygenated blood to hypoxic lung tissue. p 801

A client was admitted 3 days ago and is developing signs and symptoms of pneumonia. Select the correct documentation of the diagnosis.

Nosocomial pneumonia Explanation: Pneumonia can be classified according to the type of organism causing the infection (typical or atypical), location of the infection—lobar pneumonia or bronchopneumonia—and setting in which it occurs—community- or nosocomial/hospital-acquired pneumonia. Community-acquired pneumonia involves infections from organisms that are present more often in the community than in the hospital or nursing home. Hospital-acquired (nosocomial) pneumonia is defined as a lower respiratory tract infection occurring 48 hours or more after admission. p 784

The nurse is assessing a client suspected of having blastomycosis. Which symptoms assessed would the nurse document as characteristic of this disease? Select all that apply.

Pleuritic pain Purulent sputum Aching joints and muscles Productive cough Fever Explanation: The symptoms of acute infection, which are similar to those of acute histoplasmosis, include fever, cough, aching joints and muscles, and sometimes pleuritic pain. In contrast to histoplasmosis, the cough in blastomycosis often is productive, and the sputum is purulent. p 793

which characteristic of the lungs of infants and small children creates an increased risk of respiratory disorders? Smaller airways create a susceptibility to changes in airway resistance and airflow. Explanation: Because the resistance to airflow is inversely related to the fourth power of the radius (resistance = 1/radius), relatively small amounts of mucus secretion, edema, or airway constriction can produce marked changes in airway resistance and airflow. Surfactant production is low early in life, and the respiratory center and chemoreceptors are present and functional in infants and children. p 798

Smaller airways create a susceptibility to changes in airway resistance and airflow. Explanation: Because the resistance to airflow is inversely related to the fourth power of the radius (resistance = 1/radius), relatively small amounts of mucus secretion, edema, or airway constriction can produce marked changes in airway resistance and airflow. Surfactant production is low early in life, and the respiratory center and chemoreceptors are present and functional in infants and children. p 798

A 65-year-old man has just been diagnosed with hypercalcemia with a chronic cough and hemoptysis. The physician suspects cancer. Which cancer is most likely?

Squamous cell carcinoma Explanation: Hypercalcemia is seen most often in persons with squamous cell carcinoma, hematologic syndromes in persons with adenocarcinomas, and the remaining syndromes in persons with small-cell neoplasms. Manifestations of the paraneoplastic syndrome may precede the onset of other signs of lung cancer and may lead to discovery of an occult tumor.

Which type of lung cancer is associated with the best prognosis in most clients?

Squamous cell carcinoma Explanation: Although all forms of lung cancer are serious and potentially fatal diagnoses, individuals with small cell lung cancer, adenocarcinoma, and large cell lung cancer often face prognoses that are worse than those associated with squamous cell lung cancer. Squamous cell carcinoma tends to originate in the central bronchi as an intraluminal growth, thus it is more amenable to early detection through cytologic examination of the sputum than other forms of lung cancer. p 795

A client with a severe case of tuberculosis is prescribed a medication that will have to be given in injection form. Which medication will the nurse prepare to administer?

Streptomycin Explanation: Streptomycin, the first drug found to be effective against tuberculosis, must be given by injection, which limits its usefulness, particularly in long-term therapy. However, it remains an important drug in tuberculosis therapy and is used primarily in people with severe, possibly life-threatening forms of tuberculosis. p 791

A client had a tuberculin skin test (TST) performed as part of the immigration process and is surprised that the results are positive. How should the nurse best interpret this result?

The client was exposed to the tubercle bacillus at an indefinite point in the past. Explanation: A positive reaction to the TST does not mean that a person has active tuberculosis, only that there has been exposure to the bacillus and that cell-mediated immunity to the organism has developed. Tuberculosis has no genetic component to its etiology and a positive TST does not guarantee an active future infection. p 789

When a previously unexposed immunocompetent person is exposed to a person with tuberculosis, the pathogenesis is centered around which physiologic development?

The initiation of a cell-mediated immune response Explanation: The pathogenesis of tuberculosis, in previously unexposed immunocompetent people, is a cell-mediated immune response that confers resistance to the organism and development of hypersensitivity to the tubercular antigens. Pathologic manifestations of tuberculosis, such as caseating granuloma and cavitation, are the result of the hypersensitivity reaction rather than its inherent destructive capabilities. In persons with intact cell-mediated immunity, the cell-mediated immune response results in the development of a granulomatous lesion, called a Ghon focus, that contains the tubercle bacilli, modified macrophages, and other immune cells. p 788

An older adult client admitted to the hospital with tuberculosis becomes cyanotic, tachycardic, and develops a fever and cough. Chest x-ray reveals pus in the pleural space. What is the most likely diagnosis?

Tuberculous empyema due to primary progressive tuberculosis Explanation: Primary progressive tuberculosis represents either reinfection from inhaled droplet nuclei or reactivation of a previously healed primary lesion. It often occurs in situations of impaired body defense mechanisms. In primary progressive tuberculosis, the cell-mediated hypersensitivity reaction can be an aggravating factor, as evidenced by the frequency of cavitation and bronchial dissemination. The cavities may coalesce to a size of up to 10 to 15 cm in diameter. Pleural effusion and tuberculous empyema are common as the disease progresses. p 790

A parent brings a child into the urgent care clinic. The health care provider suspects the child has a "common cold" based on which clinical manifestations? Select all that apply.

Watery, clear nasal secretions Coughing Mild fever Explanation: The condition usually begins with a sore and scratchy throat followed by profuse and watery rhinorrhea, nasal congestion, sneezing, and coughing. Other cold symptoms include malaise, fatigue, headache, hoarseness, sinus congestion, and myalgia. Fever is a common sign in children. Photosensitivity and nuchal rigidity are signs of meningitis. p 782

A client comes to an urgent care center. The nurse notes that the client has a fever of 103.2°F (39.5°C), pleuritic pain with each breath, and enlarged lymph nodes in the neck and axilla area. The client also has a productive cough. The nurse should consider tuberculosis if the client's history includes:

intravenous drug abuse and living on the streets. Explanation: Tuberculosis is more common among foreign-born persons from countries with a high incidence of tuberculosis, as well as among residents of high-risk congregate settings such as correctional facilities, drug treatment facilities, and homeless shelters. Not finishing prescribed antibiotics can result in antibody-resistant infections (not TB); working outdoors does not place one at high risk for TB; eating food from food kitchens does not place one at risk for TB.

Non-small cell lung cancers (NSCLCs) mimic small cell lung cancers (SCLCs) through their abilities to:

synthesize bioactive products and produce paraneoplastic syndromes. Explanation: The NSCLCs include squamous cell carcinomas, adenocarcinomas, and large cell carcinomas. As with the SCLCs, these cancers have the capacity to synthesize bioactive products and produce paraneoplastic syndromes. NSCLCs do not neutralize bioactive syndromes. In addition, they neither synthesize ACTH nor produce pan-neoplastic syndromes. p 795