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 D

Explanation

A. Takes a first step alone: This is typically achieved closer to 12 months.

B. Sits alone unsupported: Some 8-month-olds might achieve this, but pulling to sit is a more consistent milestone at this age.

C. Can feed self finger food: While some babies might explore finger foods at 8 months, independent feeding is usually a skill developed later.

D. Pulls self to sitting position: This demonstrates developing upper body strength and coordination, commonly seen around 8-9 months.

A. Assess daily alcohol intake. B. Identify signs of depression. C. Determine cognitive status. D. Review risk factors for abuse.

Correct Answer is C

Explanation

A. Assess daily alcohol intake: Alcohol misuse can contribute to a variety of psychiatric symptoms, including hallucinations or delusions. Older adults may metabolize alcohol differently, leading to higher susceptibility to its effects. While this is important, it may not be the first priority unless there are clear signs of alcohol misuse (e.g., smell of alcohol, history provided by the client or family).

B. Identify signs of depression: Depression in older adults can sometimes present with psychotic features, including hallucinations or delusions. Understanding the client's emotional state and identifying symptoms of depression can provide insight into the cause of their behaviour. Depression is common in older adults and can be a precursor or a component of other psychiatric conditions.

C. Determine cognitive status: Cognitive impairment (e.g., dementia) can often present with hallucinations or delusions, and evaluating cognitive status can help differentiate between different types of disorders (e.g., dementia vs. primary psychotic disorders). Assessing cognitive function helps in identifying conditions like Alzheimer's disease or other dementias where hallucinations can be a symptom. This assessment can guide the further direction of evaluation and treatment, making it a critical first step.

D. Review risk factors for abuse: Older adults are at risk of abuse, which can include physical, emotional, and financial abuse. Identifying these risk factors is crucial for their safety and well-being. While this is a significant concern, unless there are immediate signs or disclosures of abuse, it may not be the most urgent assessment in the context of hallucinations.

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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

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Explanation

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Correct Answer is C

Explanation

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