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 B

Explanation

Rationale:
A. Pain: Pain elicited during percussion is abnormal and suggests underlying pathology, such as peritonitis, inflammation, or an organ-related issue. A healthy abdomen should not be painful during percussion.

B. Musical and drum like: A tympanic, musical, drum-like sound is the expected normal finding when percussing most areas of the abdomen. Tympany reflects the presence of air within the stomach and intestines, which is typical in a healthy gastrointestinal tract.

C. Absent sounds: Absent sounds are assessed during auscultation, not percussion. Silence during auscultation may indicate a bowel obstruction or ileus, but it is unrelated to the expected percussion findings.

D. Absolute dullness: Dullness can be a normal finding over solid organs like the liver or full bladder, but absolute or widespread dullness across the abdomen is abnormal and may suggest fluid accumulation (ascites) or masses.

A. Localized sternal border pain intensified by palpation. B. Chest pain that intensifies upon chest excursion. C. Anterior thorax pain that radiates between the scapulae. D. Pain in the neck, jaw, or medial side of the left arm.

Correct Answer is D

Explanation

Rationale:
A. Localized sternal border pain intensified by palpation: Pain that worsens with palpation suggests musculoskeletal causes such as costochondritis rather than cardiac ischemia. Cardiac chest pain is usually deep, pressure-like, and not reproducible with touch.

B. Chest pain that intensifies upon chest excursion: Pain that worsens with breathing movements often points to pleuritic causes such as pulmonary embolism or pleurisy, not myocardial infarction. Cardiac chest pain is generally constant and unaffected by breathing patterns.

C. Anterior thorax pain that radiates between the scapulae: Pain radiating between the scapulae is more characteristic of aortic dissection rather than a typical acute myocardial infarction, though some cardiac conditions can cause atypical pain patterns.

D. Pain in the neck, jaw, or medial side of the left arm: Referred pain to the neck, jaw, or inner left arm is classic for an acute myocardial infarction. This pattern reflects nerve pathways from the heart and is a hallmark symptom that strongly indicates myocardial ischemia.

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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

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Explanation

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