While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

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

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

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

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

Answer and Explanation

The Correct Answer is B

A. Explain to the client the possible causes of dyspnea or "shortness of breath.": While the nurse might eventually explain this, it's premature without more information about the client's specific shortness of breath experience.

B. Ask the client to describe the episodes of dyspnea in more detail: This is the most appropriate next step. Understanding the characteristics, triggers, and severity of the dyspnea will help determine the cause and guide further assessment.

C. Document "dyspnea on exertion" in the client's medical record: The client only reports experiencing shortness of breath "at times," not necessarily with exertion. More details are needed before documenting.

D. Ask the client to perform light exercise and observe the respiratory effort: This could worsen the client's condition if the shortness of breath is severe. Observation during rest provides a safer approach initially.

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Correct Answer is D

Explanation

A. Distal interphalangeal joint nodules that deviate: While Heberden's nodes can cause some stiffness or limited movement, "deviate" implies a significant bend or dislocation, which is not a typical characteristic of Heberden's nodes.

B. Proximal intertarsal joint swelling of big toe: This describes a swollen joint at the base of the big toe (likely gout) and is not related to Heberden's nodes, which affect the fingers.

C. Frozen, non-movable phalangeal joints: Heberden's nodes do not cause joints to become frozen or immobile. This description more accurately fits conditions like severe arthritis or advanced stages of rheumatoid arthritis where joint mobility can be significantly impaired

D. Non-painful enlarged distal interphalangeal (DIP) joints: This accurately describes Heberden's nodes, which are bony growths that typically occur on the DIP joints (closest to the fingertip) and are often painless in the early stages

A. Absolute dullness. B. Absent sounds. C. Pain. D. Musical and drum like.

Correct Answer is D

Explanation

A. Absolute dullness: This typically indicates fluid or a mass in the abdomen and is not a normal finding.

B. Absent sounds: Complete absence of bowel sounds can be a sign of an obstruction or ileus.

C. Pain: Pain during percussion suggests inflammation or irritation in the underlying organs.

D. Musical and drum like sounds: These are normal bowel sounds produced by gas and fluid movement within the intestines.

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While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

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Naxlex Comprehensive Predictor Exams

During a health assessment, the client reports being treated for osteoarthritis. The nurse examines the client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

Correct Answer is D

Explanation

The nurse completes percussion of the abdomen on an adult client. Which finding is considered normal?

Correct Answer is D

Explanation

While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

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In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?