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 B

Explanation

A. While notifying the healthcare provider is important if there are significant changes in the client's level of consciousness, it should not be the immediate next step. Before alerting the provider, the nurse needs to perform additional assessments to determine the extent of the client's unresponsiveness and gather more information about their neurological status.
B. Observing for eye opening in response to a painful stimulus is a critical step in assessing the depth of unconsciousness. This response helps determine the client's level of consciousness and can provide information about the severity of their condition.
C. Checking the pupillary response to light is important in evaluating neurological function and can provide information about brainstem activity and potential neurological deficits. However, it is secondary to checking for responses to stimuli like painful stimuli if the client is not opening their eyes spontaneously. Pupillary response should be assessed as part of a comprehensive neurological exam.
D. Asking the client to open his eyes might not be effective if the client is unresponsive or has impaired consciousness. If the client is not responding spontaneously, it is likely that verbal commands will also be ineffective. This step is less useful when assessing levels of consciousness compared to more objective assessments like responses to painful stimuli.

A. Gently press over each shin and measure indentation. B. Use a goniometer to measure and compare the legs. C. Compare the appearance of the legs bilaterally. D. Observe the client during heel-toe ambulation.

Correct Answer is C

Explanation

A. Pressing over the shins to measure indentation is a technique used to assess for edema, not muscle atrophy. Edema refers to fluid accumulation in the tissues, which can cause an indentation when pressed, whereas muscle atrophy involves a reduction in muscle mass and would not be detected by this method.
B. A goniometer is a tool used to measure the range of motion of joints, not muscle size. While it can be useful in assessing joint mobility and flexibility, it does not provide information about muscle mass or atrophy.
C. Comparing the appearance of the legs bilaterally is an appropriate method to assess for muscle atrophy. By visually inspecting and palpating both legs, the nurse can identify differences in muscle bulk and size. Muscle atrophy often presents as noticeable asymmetry between the two legs, with one leg appearing smaller or thinner compared to the other.
D. Observing the client during heel-toe ambulation can help assess gait and functional mobility, but it is not the most direct method for evaluating muscle atrophy. While gait abnormalities can suggest underlying muscle weakness or atrophy, direct visual and palpation comparison of muscle mass provides a clearer assessment of muscle atrophy.

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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

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Correct Answer is B

Explanation

To assess for muscle atrophy in the legs, which action should the nurse take?

Correct Answer is C

Explanation

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

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