The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document?

Oriented x 3.

Oriented x 1.

Oriented x 2.

Oriented x 4.

Answer and Explanation

The Correct Answer is C

A.   Being oriented x 3 means the client is aware of their name, the current time (or day), and the location (place). In this case, since the client is only able to remember his name and where he is, but not the time, day, or date, this documentation would be incorrect. The client does not meet the criteria for being oriented x 3.
B.   Being oriented x 1 means the client is aware of only one aspect of orientation, such as their name. Since the client is able to remember both his name and his location, documenting as oriented x 1 would not fully capture the extent of the client's orientation. The client is oriented to more than one aspect.
C.   Being oriented x 2 means the client is aware of two aspects of orientation. In this case, since the client is able to remember his name and his location (but not the time, day, or date), documenting as oriented x 2 accurately reflects his level of orientation.
D.   Being oriented x 4 means the client is aware of four aspects: their name, the current time (or day), the date, and the location. Given that the client can only remember his name and location, this
documentation would be incorrect as it does not align with the client’s current state of orientation.

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Correct Answer is C

Explanation

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. Gently press over each shin and measure indentation. B. Use a goniometer to measure and compare the legs. C. Compare the appearance of the legs bilaterally. D. Observe the client during heel-toe ambulation.

Correct Answer is C

Explanation

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.

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The nurse reorients a male client to the correct time, day, date, and location, but he is only able to remember his name and where he is. Based on these findings, which should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client, the nurse notes an audible expiratory wheeze and a respiratory rate of 30 breaths/minute. Which action should the nurse implement?

Correct Answer is C

Explanation

To assess for muscle atrophy in the legs, which action should the nurse take?

Correct Answer is C

Explanation

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