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

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

"I sleep on three pillows at night."

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

"I have multiple attacks of wheezing almost daily."

Answer and Explanation

The Correct Answer is B

A. "It doesn't take much activity before I'm out of breath.": This statement describes exertional dyspnea, which is shortness of breath with physical activity. It is often seen in heart or lung conditions but does not point to orthopnea, which occurs when lying flat.

B. "I sleep on three pillows at night.": Using multiple pillows to sleep is a compensatory behavior for orthopnea. Orthopnea is defined as difficulty breathing while lying flat, often related to heart failure and pulmonary congestion, and is relieved by elevating the head.

C. "I cough a lot at night and it keeps me up half the night.": Nocturnal coughing may indicate asthma, GERD, or postnasal drip. While it disrupts sleep, it does not clearly signify orthopnea, which is specifically related to positional shortness of breath.

D. "I have multiple attacks of wheezing almost daily.": Frequent wheezing attacks are more consistent with conditions like asthma or COPD. This symptom does not suggest orthopnea, which involves positional breathing difficulty, not episodic wheezing.

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Correct Answer is C

Explanation

A. Ecchymosis: Ecchymosis refers to larger areas of bruising or discoloration due to bleeding under the skin, typically caused by trauma. It appears as purple or bluish patches but does not present as tiny pinpoint spots.

B. Hematoma: A hematoma is a localized collection of blood under the skin or tissue that results in swelling and discoloration. It is typically raised and larger than petechiae, often caused by blunt force trauma.

C. Petechiae: Petechiae are small, pinpoint, round red or purple spots caused by minor bleeding under the skin. They are flat, do not blanch with pressure, and are often associated with pressure or trauma. In the context of intimate partner violence, petechiae can be a sign of strangulation or other abuse-related injuries.

D. Vesicle: A vesicle is a small, fluid-filled blister on the skin, commonly associated with infections like herpes or chickenpox. They appear as a raised lesion containing clear fluid. It is not red or pinpoint in appearance and would not match the described findings in this scenario.

A. Document the client's history that is directly related to current admission diagnoses. B. Enter the information in the electronic medical record at the client's bedside. C. Enter subjective data in the note section of the client's electronic medical record. D. Document the assessment findings on the computer at the nursing station.

Correct Answer is B

Explanation

A. Document the client's history that is directly related to current admission diagnoses:

While focusing on relevant history is important, a comprehensive health history should also include past medical, surgical, and family history to provide a full clinical picture. Limiting documentation to only current issues may omit key information.

B. Enter the information in the electronic medical record at the client's bedside:

Documenting at the bedside promotes accuracy, ensures real-time data entry, and allows the nurse to clarify details immediately with the client. This approach enhances communication, reduces errors, and supports patient-centered care.

C. Enter subjective data in the note section of the client's electronic medical record:

Subjective data should be appropriately recorded in designated fields within the health history or assessment section of the electronic record, not solely in the note section, to maintain organization and accessibility for all healthcare providers.

D. Document the assessment findings on the computer at the nursing station:

Waiting to chart at the nursing station increases the risk of memory lapses or incomplete documentation. It can lead to inaccuracies compared to bedside documentation, especially for complex or nuanced findings like those in seizure assessments.

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

Nursing Test Bank

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