An older adult client with a history of heart failure (HF) comes to the clinic troubled by awakening during the night in a cold sweat, accompanied by difficulty breathing, and a racing heart beat. Which assessment should the nurse complete first?

Assess the elasticity of the client's skin.

Auscultate the client's breath sounds.

Ask about any environmental allergies

Measure the client's core temperature.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Assess the elasticity of the client's skin: Skin elasticity, or turgor, is useful for evaluating hydration status, especially in older adults. However, it does not address the client’s immediate complaints of nocturnal dyspnea, sweating, and tachycardia, which are potentially life-threatening signs of worsening heart failure.

B. Auscultate the client's breath sounds: Awakening with dyspnea, sweating, and a racing heartbeat are classic symptoms of paroxysmal nocturnal dyspnea, often seen in decompensated heart failure. Auscultating the lungs can quickly detect crackles or pulmonary congestion, providing critical information needed to prioritize urgent interventions.

C. Ask about any environmental allergies: Environmental allergies can cause nighttime breathing issues like nasal congestion, but the combination of cold sweats and tachycardia points more toward a cardiovascular cause rather than an allergic reaction, making this a less urgent assessment initially.

D. Measure the client's core temperature: While fever can indicate infection, it is less likely to explain the sudden onset of dyspnea and palpitations in a client with known heart failure. Addressing possible pulmonary congestion through breath sound assessment takes precedence to prevent further cardiac compromise.

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Correct Answer is A

Explanation

Rationale:
A. Press firmly on the center of the sternum: Applying firm pressure to the sternum (sternal rub) is a standard method to deliver a painful stimulus and assess for a motor or verbal response in a client with reduced LOC. It helps determine the level of responsiveness without causing injury if done correctly.

B. Shake and call the client's name: This method is used to assess arousability to verbal stimuli, which is appropriate for a mild decrease in LOC. However, when a client shows a marked reduction in consciousness, painful stimuli are needed to evaluate deeper levels of responsiveness.

C. Run a pointed object up the sole of foot: This action describes part of the Babinski reflex test, used to assess upper motor neuron function rather than responsiveness to pain. It is not a standard method for evaluating pain response in altered LOC.

D. Use aromatic spirits of peppermint: Strong smells can assess olfactory nerve function or very mild arousal, but they are ineffective for evaluating deeper levels of consciousness or responsiveness to painful stimuli.

A. "Can you recall the date the Twin Towers in New York were destroyed?" B. "What is the difference between a hamster and a rabbit as a pet?" C. "Should someone who lives in a glass house throw stones?" D. "Do you write checks if you know the bank account is overdrawn?"

Correct Answer is D

Explanation

Rationale:
A. "Can you recall the date the Twin Towers in New York were destroyed?": This question assesses memory, specifically long-term memory, rather than judgment. Remembering historical events evaluates cognitive recall ability but does not explore the client’s decision-making process.

B. "What is the difference between a hamster and a rabbit as a pet?": This question primarily assesses abstract thinking and categorization rather than judgment. It helps evaluate how the client organizes concepts but does not directly provide insight into practical decision-making or problem-solving skills.

C. "Should someone who lives in a glass house throw stones?": This proverb assesses abstract thinking and the ability to interpret symbolic meanings, rather than directly evaluating judgment. Interpretation of proverbs reflects cognitive function but not necessarily real-life decision-making capacity.

D. "Do you write checks if you know the bank account is overdrawn?": This question assesses practical judgment by exploring the client's ability to make appropriate decisions regarding real-world financial behavior. It directly addresses reasoning, consequences of actions, and impulse control, which are key elements of judgment evaluation.

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An older adult client with a history of heart failure (HF) comes to the clinic troubled by awakening during the night in a cold sweat, accompanied by difficulty breathing, and a racing heart beat. Which assessment should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which method should the nurse use to assess response to painful stimuli for a client with a marked reduction in the level of consciousness (LOC)?

Correct Answer is A

Explanation

While performing a mental status examination, which question should the nurse ask when attempting to evaluate a client's judgment?

Correct Answer is D

Explanation

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