The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? (Select all that apply)

A. Auscultating lung sounds:

Auscultating lung sounds is essential to assess for any abnormal sounds such as wheezing, crackles, or diminished breath sounds, which can provide information about the extent and nature of lung congestion.

B. Obtaining the client’s temperature:

Obtaining the client's temperature is important to assess for the presence of fever, which is a common symptom associated with respiratory infections.

C. Assessing the strength of peripheral pulses:

Assessing peripheral pulses is not directly related to cold, cough, and lung congestion symptoms. This type of assessment is more relevant in cardiovascular or peripheral vascular assessments.

D. Obtaining information about the client’s respirations:

Assessing the rate, depth, and rhythm of respirations is crucial when dealing with respiratory symptoms. This information helps determine the severity and nature of the respiratory distress.

E. Asking the client about a family history of any illness or disease:

Family history is important for a comprehensive health assessment, but for the focused assessment of a cold, cough, and lung congestion, obtaining information about the current symptoms and associated factors takes precedence.

A. Regular deep respirations interspersed with periods of apnea:

This describes periodic breathing, which is different from Cheyne-Stokes respirations. Periodic breathing consists of regular cycles of deep respirations followed by periods of apnea.

B. A pattern of crescendo-decrescendo respirations followed by a period of apnea

Cheyne-Stokes respirations are characterized by a pattern of crescendo-decrescendo respirations, meaning that the depth and rate of breathing gradually increase and then decrease. This is followed by a period of apnea, during which there is a temporary cessation of breathing. The cycle then repeats.

C. Patient breathing less than 10 breaths per minute:

This describes bradypnea, which is an abnormally slow respiratory rate. Cheyne-Stokes respirations involve rhythmic, cyclical changes in respiratory rate and depth.

D. Patient breathing shallow and more than 24 breaths per minute:

This describes tachypnea, which is an abnormally fast respiratory rate. Cheyne-Stokes respirations are characterized by a distinct pattern of alternating crescendo-decrescendo respirations followed by apnea.