During a health assessment for a young adult female client's gynecological annual screening, the client reports amenorrhea. The nurse calculates the client's body mass index (BMI) as 16 kg/m2 (normal 18.0 to 24.9 kg/m2). Which finding should the nurse document in the electronic medical record that indicates an expected rationale for this condition?

A. Auscultating all lobes of the lungs is an important step in a comprehensive respiratory assessment. It helps the nurse assess the presence and distribution of abnormal breath sounds, such as wheezing, and evaluate the overall condition of the lungs. While this is a crucial part of the assessment process, it is more of a diagnostic step rather than an immediate intervention for managing respiratory distress.
B. Placing the client in a low Fowler's position (45 degrees) can help improve ventilation and comfort, especially if they are experiencing difficulty breathing. However, in the context of audible wheezing and elevated respiratory rate, more immediate interventions to address the underlying issue are typically required.
C. Administering a respiratory aerosol treatment (such as a bronchodilator) is a direct intervention to address wheezing, which is often caused by bronchoconstriction or inflammation. Aerosol treatments can help open the airways and relieve wheezing, making this a priority action for managing the symptoms described.
D. Providing supplemental oxygen can be beneficial if the client is experiencing hypoxia (low blood oxygen levels). However, the need for oxygen should be determined based on the client's oxygen saturation levels and overall clinical picture. While oxygen can support breathing, it does not address the underlying cause of wheezing or the elevated respiratory rate directly.

A. Pressing over the shins to measure indentation is a technique used to assess for edema, not muscle atrophy. Edema refers to fluid accumulation in the tissues, which can cause an indentation when pressed, whereas muscle atrophy involves a reduction in muscle mass and would not be detected by this method.
B. A goniometer is a tool used to measure the range of motion of joints, not muscle size. While it can be useful in assessing joint mobility and flexibility, it does not provide information about muscle mass or atrophy.
C. Comparing the appearance of the legs bilaterally is an appropriate method to assess for muscle atrophy. By visually inspecting and palpating both legs, the nurse can identify differences in muscle bulk and size. Muscle atrophy often presents as noticeable asymmetry between the two legs, with one leg appearing smaller or thinner compared to the other.
D. Observing the client during heel-toe ambulation can help assess gait and functional mobility, but it is not the most direct method for evaluating muscle atrophy. While gait abnormalities can suggest underlying muscle weakness or atrophy, direct visual and palpation comparison of muscle mass provides a clearer assessment of muscle atrophy.