A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

Assess respiratory rate and rhythm

Pulse oximetry reading

Assess bowel sounds

Auscultate lung sounds

Determine two touch discrimination in the lower extremities

Answer and Explanation

Correct Answer : A,B,D

A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.

B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.

C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.

D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.

E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.

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Correct Answer is A

Explanation

A. "How do you handle stress?" While stress may influence some skin conditions (e.g., psoriasis, eczema), this question is not directly related to a focused skin assessment and may be too vague or irrelevant.

B. "Does your skin condition keep you awake at night?" Skin conditions such as eczema or urticaria can cause pruritus, leading to sleep disturbances. This is a relevant question.

C. "How does your skin condition make you feel about yourself?" Skin conditions can affect body image and self-esteem, making this an important question for psychosocial assessment.

D. "Have you had any changes in your diet?" Certain food allergies or deficiencies can trigger dermatologic conditions (e.g., celiac disease, atopic dermatitis), making this question appropriate.

A. 5th Intercostal Space, Midclavicular Line B. 2nd Intercostal Space, Left Sternal Border C. 2nd Intercostal Space, Right Sternal Border D. 3rd Intercostal Space, Left Sternal Border

Correct Answer is C

Explanation

A. 5th Intercostal Space, Midclavicular Line. This is the location for the apical pulse (PMI) at the mitral area, not the aortic valve.

B. 2nd Intercostal Space, Left Sternal Border. This is the location of the pulmonic valve, not the aortic valve.

C. 2nd Intercostal Space, Right Sternal Border. The aortic valve is best auscultated at the right second intercostal space, next to the sternum.

D. 3rd Intercostal Space, Left Sternal Border. This is the Erb’s point, which provides equal S1 and S2 sounds, but it is not the best location for auscultating aortic valve dysfunction.

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A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)

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Naxlex Comprehensive Predictor Exams

A nurse is observing a newly licensed nurse perform focused data collection on a client who has developed a skin condition. Which of the following questions by the newly licensed nurse requires intervention by the nurse?

Correct Answer is A

Explanation

The nurse is planning to auscultate heart sounds. The history and physical indicates a history of Aortic Valve dysfunction. Where would the nurse auscultate to assess the Aortic Valve?

Correct Answer is C

Explanation

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