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 C

Explanation

A. Eats less salt-cured meats: Reducing the intake of salt-cured meats is generally a positive behaviour, especially for someone with hypertension. This behaviour aligns with dietary recommendations for managing high blood pressure.

B. Participates in healing rituals: Healing rituals are part of many cultural practices and can provide emotional and spiritual support. However, without further information, it's unclear if these rituals interfere with the prescribed treatment. This may warrant additional assessment to ensure they complement the medical regimen.

C. Uses herbal remedies: The use of herbal remedies could potentially interact with prescribed antihypertensive medications. This behaviour requires careful assessment to ensure there are no harmful interactions or adverse effects on the treatment plan.

D. Meditates in sweat lodges: Sweat lodges are a traditional practice for many Native Americans, providing physical and spiritual cleansing. However, the high temperatures and dehydration risks associated with sweat lodges could adversely affect blood pressure control and overall cardiovascular health. This behaviour requires further evaluation to ensure it is safe for the client with hypertension.

A. Triceps skin fold and mid-arm circumference. B. Twenty-four-hour food recall, preferences, and allergies. C. Weight loss history and body surface area (BSA) D. Body mass index (BMI) and serum albumin level.

Correct Answer is D

Explanation

A. Triceps skin fold and mid-arm circumference. These measurements can provide some indication of nutritional status, but they may not be as reliable in older adults due to changes in body composition and skin elasticity.

B. Twenty-four-hour food recall, preferences, and allergies. While dietary information is important, it may not accurately reflect the client's current nutritional status.

C. Weight loss history and body surface area (BSA). While weight loss history is relevant, BSA is not typically used to assess nutritional status.

D. Body mass index (BMI) and serum albumin level. BMI is a commonly used indicator of nutritional status, and serum albumin level reflects protein status, which is important for assessing malnutrition.

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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

An older Native-American client with hypertension presents to an outpatient clinic for follow-up evaluation after initiation of treatment with oral antihypertensive medications. Report of which client behavior requires additional assessment by the nurse?

Correct Answer is C

Explanation

The nurse is admitting an older adult client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

Correct Answer is D

Explanation

To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

During a routine physical examination of a client, chest palpation is determined to be normal except for a 2 inch (5.1 cm) diameter area of crepitus over the upper right anterior chest. Which interpretation is the most accurate for this finding?

In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?