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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Free Nursing Study Resources

Correct Answer is ["60"]

Explanation

Convert weight from pounds to kilograms:

165lb÷2.2=75kg

Multiply by the Recommended Dietary Allowance (RDA) for protein:

75kg×0.8g/kg=60g

A. Kyphosis B. Scoliosis C. Lordosis D. Ankylosis

Correct Answer is A

Explanation

A. Kyphosis: Excessive forward curvature of the thoracic spine, commonly due to osteoporosis-related bone loss in older adults.

B. Scoliosis refers to a lateral curvature of the spine.

C. Lordosis: exaggerated inward curvature of the lumbar spine, often seen in pregnancy or obesity.

D. Ankylosis: abnormal stiffening or fusion of joints, unrelated to spinal curvature.

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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)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["60"]

Explanation

A nurse is collecting data from an older adult client who has had some bone density loss. The nurse observes excessive forward curvature of the thoracic spine. The nurse should document this finding using which of the following terminology?

Correct Answer is A

Explanation

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?

A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching?

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

A nurse is collecting data from a client who reports finding a new skin lesion. Which of the following actions is the nurse's priority?

A nurse is planning to perform passive range of motion for a client who is immobilized. Which of the following actions should the nurse plan to take?

A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?