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 D

Explanation

A. Borborygmi sounds: Borborygmi are loud, prolonged, gurgling bowel sounds typically associated with increased gastrointestinal motility. They are usually heard without a stethoscope and are often linked to hunger or certain GI conditions, not the normal rhythm described.

B. Hyperactive bowel sounds: These are frequent, high-pitched, loud sounds that may occur more than 30 times per minute. They are associated with diarrhea, gastroenteritis, or early bowel obstruction—not the steady, moderate-frequency sounds described.

C. Hypoactive bowel sounds: These are infrequent bowel sounds (fewer than 5 per minute), often soft and low-pitched, possibly indicating slowed intestinal activity from surgery, inflammation, or ileus. The client’s pattern of sounds every 5–10 seconds does not meet this definition.

D. Normal bowel sounds: Bowel sounds occurring every 5 to 15 seconds and lasting a few seconds (gurgles, clicks) are considered normal. These reflect regular peristaltic activity and digestion, making this the correct documentation for the described findings.

A. Perform passive range of motion and compare the findings. B. Instruct client to walk across room and observe the gait. C. Compare measured circumferences of each extremity joint. D. Measure the length of each leg and document the findings.

Correct Answer is D

Explanation

A. Perform passive range of motion and compare the findings: While assessing range of motion may help identify functional limitations or stiffness, it does not directly address the issue of leg asymmetry, which may be due to structural differences rather than functional impairment.

B. Instruct client to walk across room and observe the gait: Gait analysis is important for evaluating mobility and balance, but it doesn't directly address the underlying cause of leg asymmetry, especially if the asymmetry is due to a structural or anatomical issue rather than a functional one.

C. Compare measured circumferences of each extremity joint: Comparing circumferences can help identify swelling or muscle wasting, but it does not address leg length discrepancies or structural differences that could be contributing to the asymmetry.

D. Measure the length of each leg and document the findings: Measuring leg length is the most appropriate action to assess for a potential leg length discrepancy, which is a common cause of asymmetry. This will help determine if the asymmetry is structural (due to bone length differences) or due to other causes.

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

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Naxlex Comprehensive Predictor Exams

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