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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Plan to measure the blood pressure in four hours as prescribed. Waiting for another four hours may not be appropriate given the significant increase in blood pressure. Immediate action is needed to address the elevated reading.
B. Repeat the client’s blood pressure measurement in fifteen minutes. This is the most appropriate action. When a client’s blood pressure is significantly elevated, it’s essential to recheck it promptly to confirm accuracy and assess for any changes. Fifteen minutes allows enough time for a follow-up measurement without unnecessary delay.
C. Obtain an automatic blood pressure machine for hourly readings. While continuous monitoring is valuable in some situations, it’s not necessary for routine blood pressure assessments. Hourly readings would be excessive and may not provide additional useful information.
D. Reassess the blood pressure if the client reports other symptoms. While assessing other symptoms is essential, waiting for symptoms to occur before reassessing blood pressure is not the best approach. Immediate follow-up is warranted based on the elevated reading alone
Correct Answer is A
Explanation
A. Kyphosis: A rounding of the upper back, causing a hunchback appearance. While it can also be caused by other conditions, a mild kyphosis is a common finding in older adults due to weakening muscles and spinal compression.
B. Barrel chest: This refers to a chest that is fixed in an outward position, often caused by chronic obstructive pulmonary disease (COPD) or other lung conditions.
C. Lordosis: An exaggerated inward curve of the lower back, which is not a typical feature of normal aging.
D. Pectus excavatum: A sunken appearance of the chest wall, usually a congenital condition present from birth.
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