A client presents with increasing fatigue, shortness of breath with exertion, and a reported wheezing sound that a family member heard. What initial step should the nurse take to assess for respiratory distress?
Encourage the client to rest and monitor their symptoms for a few hours
Instruct the client to take slow, deep breaths to control their anxiety
Perform a focused respiratory assessment, including auscultating lung sounds
Request the client to complete pulmonary function tests immediately
The Correct Answer is C
Reasoning:
Respiratory distress is characterized by an inadequate gas exchange or increased work of breathing. When a client reports symptoms like dyspnea and wheezing, the nurse must immediately objectively evaluate the ventilation and oxygenation status. This focused assessment provides the necessary clinical data to determine the severity of the respiratory compromise.
A. Monitoring symptoms for a few hours is an unsafe delay in care for a client reporting shortness of breath and audible wheezing. Respiratory conditions can deteriorate rapidly. The nurse must act immediately to assess the patient's airway and breathing rather than waiting to see if the symptoms improve with rest.
B. Assuming that the client's symptoms are caused by anxiety without first ruling out physical respiratory pathology is a significant clinical error. While anxiety can cause dyspnea, the report of wheezing suggests a physiological obstruction or narrowing of the airways (bronchospasm) that requires objective assessment and medical intervention.
C. The nurse must perform a focused respiratory assessment, which includes checking the respiratory rate, rhythm, and depth, measuring oxygen saturation, and auscultating for adventitious breath sounds like wheezes or crackles. This physical examination is the essential first step in the nursing process to identify the nature of the distress.
D. Pulmonary function tests (PFTs) are diagnostic tools used to evaluate chronic lung conditions, but they are not the "initial" assessment step during an acute presentation of respiratory distress. Furthermore, PFTs are usually ordered by a provider after the nurse has completed a physical assessment and reported the findings.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reasoning:
Infantile colic is a behavioral syndrome characterized by excessive, paroxysmal crying in otherwise healthy infants, typically following the rule of three: crying for more than 3 hours a day, 3 days a week, for 3 weeks. It is often associated with abdominal distension and inconsolable distress.
A. There are currently no evidence-based pharmacological treatments recommended for the routine management of infantile colic. While simethicone is sometimes used to reduce intestinal gas, its efficacy is clinically debated. Management focuses primarily on parental support, soothing techniques, and occasionally dietary modifications if a sensitivity is suspected.
B. By definition, colic is an idiopathic condition, meaning it occurs in infants who are otherwise healthy and thriving without an underlying organic medical disease. If a specific medical condition like gastroesophageal reflux or a urinary tract infection is found, the crying is no longer classified as colic.
C. The crying associated with colic is distinct from normal hunger or fatigue cues; it is often described as a scream of pain or an urgent, high-pitched vocalization. These episodes are intense, sudden, and often include physical signs such as clenched fists, a flushed face, and drawn-up legs.
D. Epidemiological data indicates that colicky episodes follow a diurnal rhythm, most frequently occurring or intensifying in the late afternoon and evening hours. It is rarely a morning phenomenon, and the clustering of symptoms toward the end of the day is a hallmark diagnostic feature.
Correct Answer is B
Explanation
A fever, or pyrexia, triggers a hypermetabolic state characterized by an elevation in the hypothalamic set point. To meet the increased metabolic oxygen demands of the tissues during a febrile episode, the autonomic nervous system increases the cardiac output, typically resulting in a predictable rise in the heart rate.
A. Erythema refers to redness of the skin, which is generally a localized manifestation of inflammation or infection. While a fever can cause generalized flushing, erythema is more commonly used to describe a specific area of localized skin irritation or injury rather than a whole-body systemic response.
B. Tachycardia is a classic systemic manifestation of fever. For every 1 degree increase in body temperature, the heart rate typically increases by approximately 10 beats per minute. This occurs because the body requires more oxygen to support the increased metabolic rate associated with fighting an infection.
C. Edema is the localized or generalized accumulation of fluid in the interstitial spaces. While it can occur in systemic conditions like heart or kidney failure, it is not a direct systemic diagnostic manifestation of a fever itself. It is usually related to vascular permeability or hydrostatic pressure changes.
D. Purulent drainage is a localized sign of infection, consisting of white blood cells, dead tissue, and bacteria (pus). It is observed at the specific site of a wound or abscess. It is not a systemic finding that characterizes the body's overall thermoregulatory response to an infectious process.
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