Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

"I cough a lot at night and it keeps me up half the night."

"I sleep on three pillows at night."

" have multiple attacks of wheezing almost daily."

"It doesn't take much activity before I'm out of breath."

Answer and Explanation

The Correct Answer is B

A. "I cough a lot at night and it keeps me up half the night." Night-time coughing can be associated with various conditions, including asthma, GERD, or postnasal drip, but it is not specifically indicative of orthopnoea.

B. "I sleep on three pillows at night." This supports orthopnoea, which is difficulty breathing when lying flat. Clients with orthopnoea often use multiple pillows to elevate their upper body to alleviate shortness of breath.

C. "I have multiple attacks of wheezing almost daily." Frequent wheezing is more indicative of asthma or other obstructive airway diseases, not orthopnoea.

D. "It doesn't take much activity before I'm out of breath." This describes dyspnoea on exertion, which is different from orthopnoea, as it refers to difficulty breathing during physical activity rather than when lying down.

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Correct Answer is B

Explanation

A. Documenting asymmetrical thoracic movement: While this might be a finding, it's not the most urgent action.

B. Assist the client to a position that helps the client breathe more easily. Sternocleidomastoid, trapezius, and abdominal muscle use: These muscles are accessory muscles that help with breathing when the diaphragm and intercostal muscles (primary muscles of respiration) are not functioning optimally. This use suggests laboured breathing. Priority action: The client's respiratory distress is the most pressing concern.

C. Incentive spirometer: This device helps improve lung expansion but is not the first-line intervention in this situation where the client is already struggling to breathe.

D. Encouraging deep breaths: This might further strain the respiratory muscles.

A. The gallbladder is normal. B. Deeper palpation technique is needed. C. The client is too obese. D. Palpating in the wrong abdominal quadrant.

Correct Answer is A

No explanation

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Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is A

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