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 B

Explanation

A. Distinguish between symptoms caused by disease and those due to aging: While differentiating age-related changes from disease symptoms is important, it is a general consideration. It does not directly address safety or management concerns specific to this client’s multiple chronic conditions and recent surgical history.

B. Obtain a medication history including prescription and nonprescription drugs: This is the most crucial step, especially in older adults with multiple chronic conditions. Polypharmacy increases the risk of drug interactions, side effects, and complications especially after surgery or when managing conditions like hypertension, arthritis, and constipation.

C. Emphasize the need to place advance directives in the medical record: While advance directives are important for long-term care planning, they are not an immediate priority in a routine follow-up unless there is a known acute or terminal condition that requires urgent decision-making support.

D. Conduct an assessment of functional capacity and environmental hazards: This is relevant for fall prevention and maintaining independence, particularly after eye surgery. However, ensuring accurate medication use and identifying potential interactions or duplications takes precedence in immediate clinical relevance.

A. A change in awareness of surroundings. B. Reduced fine motor skills. C. A negative Babinski reflex. D. Diminished short term memory over the past year.

Correct Answer is A

Explanation

A. A change in awareness of surroundings: Altered awareness or sudden changes in level of consciousness can signal acute neurological issues such as stroke, brain injury, infection, or metabolic imbalances. This is a serious red flag requiring immediate medical evaluation to prevent potential deterioration.

B. Reduced fine motor skills: While reduced fine motor skills can indicate a neurological issue, it typically develops gradually due to conditions like arthritis, neurological disorders, or aging and may be monitored unless associated with other acute symptoms. It is not usually an emergency unless sudden in onset.

C. A negative Babinski reflex: A negative Babinski reflex is a normal finding in adults, indicating intact central nervous system function. It does not suggest the need for medical follow-up in the absence of other abnormal signs.

D. Diminished short term memory over the past year: Gradual memory decline may indicate cognitive changes like dementia, stress or early signs of cognitive impairment but it typically requires routine, not immediate, follow-up unless there's a rapid worsening or associated concerning symptoms.

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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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