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 B

Explanation

A. Request social services to make a home visit. This is important but not the immediate priority. It can be part of the long-term intervention plan once the immediate safety and health of the client are ensured.

B. Interview the client privately without the adult child present. This is the highest priority. It allows the nurse to assess for potential abuse or neglect without the influence or intimidation of the accompanying adult, ensuring the client can speak freely.

C. Complete a neurological and musculoskeletal assessment. This is important to assess the extent of the injuries and the client's overall physical health, but it follows the immediate need to ensure the client's safety and ability to speak freely about their situation.

D. Ask the client if an assisted living facility is an option for safety concerns. While exploring living arrangements is important for long-term safety, it is not the highest priority. Ensuring the client's immediate safety and obtaining accurate information about their situation takes precedence.

A. Contact social services for a temporary shelter. B. Obtain a hemoglobin and hematocrit level. C. Have the client transported to the hospital. D. Schedule weekly perinatal appointments.

Correct Answer is C

Explanation

A. Contact social services for a temporary shelter. While contacting social services is important for the overall care of a homeless pregnant woman, it is not the immediate priority in the presence of placenta previa and vaginal bleeding.

B. Obtain a hemoglobin and hematocrit level. Assessing hemoglobin and hematocrit levels is important to evaluate the extent of blood loss and anemia, but the priority is to ensure the woman’s and fetus’s immediate safety due to placenta previa.

C. Have the client transported to the hospital. This is the correct action. Placenta previa can cause significant bleeding and requires immediate medical attention, including potential delivery. Transporting the client to the hospital ensures she receives the necessary urgent care.

D. Schedule weekly perinatal appointments. Weekly perinatal appointments are important for ongoing care, but in the context of active bleeding and placenta previa, immediate hospital care is necessary first.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

Correct Answer is C

Explanation

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