While ambulating the hall, the client begins to complain of shortness of breath and difficulty breathing. Which term should be documented in the client's medical record?

Tachypnea

Bradypnea

Eupnea

Dyspnea

Answer and Explanation

The Correct Answer is D

A.   Tachypnea refers to an increased respiratory rate. It is used when a client is breathing faster than normal. While tachypnea could be associated with difficulty breathing, it specifically denotes a faster- than-normal rate of breathing, not the sensation of breathlessness or difficulty.
B.   Bradypnea is the term used for a slower-than-normal respiratory rate. If a client’s breathing rate is slower than usual, bradypnea would be the appropriate term. However, this term does not describe the sensation of shortness of breath or difficulty breathing.
C.   Eupnea is the term for normal, unlabored breathing. This term is used when the client’s breathing is neither too fast nor too slow and is comfortable. It does not apply to the situation described, where the client is experiencing difficulty breathing.
D.   Dyspnea refers to the sensation of shortness of breath or difficulty breathing. It is the term used to describe the subjective experience of feeling like one cannot get enough air or is having trouble breathing.

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Correct Answer is B

Explanation

A. Palpable lymph nodes are assessed through palpation, not inspection. The nurse would use their hands to feel for lymph nodes in areas such as the axilla (armpit) and supraclavicular regions. This is a tactile examination and therefore not documented as part of the inspection.
B. Symmetry refers to the visual observation of whether the breasts are equal in size and shape. During the inspection phase, the nurse notes whether the breasts appear symmetrical or if there are any visible asymmetries.
C. Breast sensitivity is typically assessed through palpation or the client’s report of symptoms rather than through inspection alone. Sensitivity involves asking the client about their experience of pain or discomfort in the breasts, which cannot be observed visually.
D. Tenderness is assessed through palpation, where the nurse would gently press on the breast tissue to determine if the client experiences pain. Tenderness is not a visual finding and therefore is not documented during the inspection phase.

A. High pitch continuous sounds on inspiration and expiration. B. High pitched short crackling C. Low pitch continuous rattling on inspiration and expiration. D. Low pitched grating and rubbing on inhalation and exhalation.

Correct Answer is A

Explanation

A. This option describes wheezes, which are high-pitched continuous sounds often heard on both inspiration and expiration. Wheezes are commonly associated with asthma because they result from the narrowing of the airways, causing turbulent airflow.
B. This description refers to crackles (or rales), which are short, high-pitched sounds often heard on inspiration. Crackles are typically associated with conditions such as pneumonia, congestive heart failure, or other forms of pulmonary edema. They are not as specific to asthma as wheezes are.
C. This option describes rhonchi, which are low-pitched, continuous rattling sounds that may occur on both inspiration and expiration. Rhonchi are often associated with airway obstruction due to secretions or mucus and can be heard in conditions such as chronic bronchitis.
D. This option describes pleural friction rubs, which are low-pitched, grating sounds heard during both inhalation and exhalation. Pleural friction rubs occur when the pleural layers become inflamed and rub against each other.

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While ambulating the hall, the client begins to complain of shortness of breath and difficulty breathing. Which term should be documented in the client's medical record?

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Naxlex Comprehensive Predictor Exams

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Explanation

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