While obtaining a health history, a client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and his respiratory rate is 14 breaths/minute. What is the best nursing action?

Ask the client to perform light exercise and observe the respiratory effort.

Document "dyspnea on exertion" in the client's medical record.

Ask the client to describe the episodes of dyspnea in more detail.

Explain to the client the possible causes of dyspnea or "shortness of breath."

Answer and Explanation

The Correct Answer is C

A.   Performing light exercise may help in assessing how the client’s respiratory system responds to physical exertion and could reveal if the shortness of breath is related to activity. However, this action might not be appropriate if the client is currently asymptomatic or if the nurse needs more detailed information about the episodes of dyspnea.
B.   Documenting "dyspnea on exertion" might be appropriate if the nurse has already confirmed that the shortness of breath occurs specifically with physical activity. However, based on the information provided, the nurse has not yet gathered sufficient details to confirm whether the dyspnea is related to exertion or another cause.
C.   This option is the best initial action because it allows the nurse to gather detailed information about the nature, frequency, duration, and triggers of the client's shortness of breath. Understanding the context and specifics of the episodes will help in determining whether the dyspnea is related to underlying health issues, activity, or other factors.
D.   While explaining the possible causes of dyspnea can be informative for the client, it may not address the immediate need for a detailed assessment of the client's symptoms. Providing education is valuable, but understanding the client's specific experience with dyspnea should take precedence to tailor the explanation and subsequent care effectively.

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Correct Answer is A

Explanation

A. A firm mass palpated at the bottom of the left rib cage can indicate an enlarged spleen, which is an abnormal finding. Splenomegaly may occur due to various conditions, including infections, liver disease, or blood disorders.
B. Rebound tenderness in the right upper quadrant is indicative of potential inflammation or irritation in the abdominal cavity, often associated with appendicitis or other conditions affecting the right lower quadrant. This finding is not specific to the spleen but rather to the general abdominal assessment and does not indicate an abnormal response related to spleen palpation.
C. Normally, the spleen is not palpable in most people. However, if the spleen is slightly enlarged, its tip may be palpable during deep palpation or when the client is asked to exhale forcefully. While this can be an abnormal finding, it may still fall within a range of normal variability depending on the clinical context.
D. McBurney's point is located in the right lower quadrant of the abdomen and is associated with the appendix. Pain at this location is indicative of potential appendicitis, not an abnormal finding related to spleen palpation. This finding does not provide information about the condition of the spleen.

A. Hyperactive bowel sounds are present in all quadrants. B. Small frequent meals cause heartburn to worsen. C. Heartburn occurs when lying down at night. D. Bowel movements are light grey and chalky.

Correct Answer is C

Explanation

A. Hyperactive bowel sounds are not typically associated with gastroesophageal reflux disease (GERD). They are more indicative of gastrointestinal disturbances such as increased bowel activity or a bowel obstruction. Since the client's symptoms are related to heartburn, assessing bowel sounds is less relevant to GERD. This choice does not provide useful information for diagnosing or managing GERD.
B. This option is not commonly associated with GERD. In fact, small frequent meals are often recommended as a management strategy for GERD to reduce the occurrence of heartburn, as large meals can exacerbate symptoms by increasing stomach pressure. This choice does not align with typical GERD management strategies and may not be a useful symptom to assess in this context.
C. This finding is highly relevant for GERD. Heartburn that occurs or worsens when lying down, especially at night, is a classic symptom of gastroesophageal reflux disease. When a person lies flat, stomach acid can more easily flow back into the esophagus due to decreased gravitational pressure, leading to heartburn. Identifying this symptom helps confirm GERD and guides management strategies, such as elevating the head while sleeping or avoiding late meals.
D. Light grey and chalky stools are indicative of issues related to bile production and could suggest a problem with the liver or biliary system rather than GERD. This symptom is not associated with GERD and would be more relevant in assessing conditions such as biliary obstruction or liver disease.

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While obtaining a health history, a client tells the nurse that he sometimes experiences shortness of breath. The nurse determines that the client's respirations are regular and deep, and his respiratory rate is 14 breaths/minute. What is the best nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse examines a client's abdomen. Which finding indicates an abnormal response when palpating the spleen?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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