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. This term suggests a problem with blood flow, which could potentially cause symptoms such as numbness or tingling. However, it does not specifically address the sensation of burning. Using this term might lead to an incorrect or incomplete assessment of the client's condition.
B. Paresthesia is a term used to describe abnormal sensations in the skin, such as burning, tingling, or prickling. The client's report of a burning sensation in the hands and legs aligns well with the definition of paresthesia. Documenting it as "paresthesia reported" accurately reflects the nature of the symptoms and is a medically precise way to describe the abnormal sensory experience.
C. This documentation uses colloquial language ("on fire") to describe the client's symptoms. While it conveys the intensity of the sensation, it is not a standardized medical term and may not be as clear or useful for clinical documentation.
D. Inflammation refers to the body's response to injury or infection, which often involves redness, swelling, heat, and pain. The term "inflammation" does not specifically describe the sensation of burning reported by the client.

A. Multiple varicosities on both thighs. B. Lack of hair growth on both lower legs. C. Stage 2 pressure injury over the left ankle. D. Right calf swelling and tenderness.

Correct Answer is D

Explanation

A. Varicosities, or varicose veins, are dilated veins that appear on the skin and are often associated with venous insufficiency. While they can be symptomatic and require management, they typically do not constitute an immediate medical emergency. Varicosities are generally managed with lifestyle changes, compression therapy, or medical procedures, but they are not usually life-threatening.
B. Lack of hair growth on the lower legs can indicate poor circulation, commonly seen in conditions like peripheral arterial disease (PAD). While it is a concerning finding and suggests potential arterial insufficiency, it is not usually an immediate emergency.
C. A Stage 2 pressure injury is characterized by partial-thickness loss of dermis, presenting as a shallow, open ulcer with a pink wound bed. While it requires attention to prevent progression and manage the wound, it is not an immediate emergency compared to other findings that suggest acute complications.

D. Right calf swelling and tenderness are critical findings that could indicate a deep vein thrombosis (DVT), which is a serious condition where a blood clot forms in a deep vein, usually in the leg. DVT can lead to life-threatening complications such as pulmonary embolism if the clot dislodges and travels to the lungs.

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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

A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

Correct Answer is B

Explanation

When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

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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?

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