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 ["A","B","C","D"]

Explanation

A. Peripheral edema: Peripheral edema is a classic sign of right-sided heart failure due to venous congestion. When the heart cannot pump effectively, there is increased fluid volume and pressure in the veins causing fluid to leak into the surrounding tissues fluid accumulates in dependent areas like the legs and ankles, especially in older adults with chronic heart failure.

B. Dyspnea: Dyspnea is a key indicator of left-sided heart failure, resulting from pulmonary congestion. As the left ventricle fails to pump efficiently, fluid backs up into the lungs, impairing gas exchange and causing shortness of breath during exertion or even at rest. Dyspnea can occur at rest or with exertion and may worsen when lying flat (orthopnea) or during the night (paroxysmal nocturnal dyspnea).

C. Jugular venous distension: JVD occurs when elevated right atrial pressure causes the jugular veins to become distended. It is a significant clinical finding in right-sided heart failure and reflects systemic fluid overload and impaired venous return.

D. Intercostal retractions: Intercostal retractions are a sign of increased respiratory effort, indicating that the patient is struggling to breathe. In heart failure exacerbation, pulmonary congestion increases the work of breathing, leading to respiratory distress and visible use of accessory muscles.

E. Headaches: Headaches are not typically associated with heart failure and are not considered a reliable indicator of an exacerbation. They may be due to other causes such as hypertension, stress, or neurological issues and require separate evaluation.

A. Collect information about the client's activities since surgery. B. Conduct a comprehensive review of systems. C. Prepare to collect a vaginal specimen for Papanicolaou smear. D. Perform a head-to-toe physical assessment.

Correct Answer is A

Explanation

A. Collect information about the client's activities since surgery: Focusing the history on the client’s recovery, current symptoms, physical activity tolerance, and any complications or concerns since the hysterectomy provides the most relevant information for a postoperative follow-up. This approach helps assess healing and identify any recovery issues.

B. Conduct a comprehensive review of systems: A full review of systems is more appropriate for an annual exam or initial assessment. For a focused postsurgical visit, the nurse should prioritize gathering data related to the surgical recovery rather than reviewing unrelated body systems.

C. Prepare to collect a vaginal specimen for Papanicolaou smear: A Pap smear may not be immediately necessary post-hysterectomy, depending on the type of hysterectomy performed and the client’s cancer risk. It is not a routine part of a 6-week postoperative evaluation unless specifically ordered by the HCP.

D. Perform a head-to-toe physical assessment: A complete physical exam is typically unnecessary at a routine postoperative check unless complications are suspected. A focused history and exam centered on the surgical site and recovery are more appropriate for this visit.

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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

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm(s) to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A client reports to the healthcare provider's (HCP) office for a routine postsurgical evaluation six weeks after a hysterectomy. Which history taking approach should the nurse use to gather the needed information?

Correct Answer is A

Explanation

The nurse continues a neurologic assessment of the cranial nerve XI (spinal accessory) for a client as seen in the picture. Which instruction should the nurse give the client to complete this assessment?

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

An older adult male client reports nocturia with difficulty starting his urine stream. Which additional assessment should the nurse perform to obtain further data related to this information?

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. Which does this finding indicate?

An adult male client tells the nurse that he smokes approximately one pack of cigarettes daily. How can the nurse expect smoking to affect this client's sleep?

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain data to support the client's statement?