A client presents with complaints of anxiety, restlessness, and increased work of breathing. Which assessments should the nurse perform? (Select all that Apply)
Assess respiratory rate and rhythm
Pulse oximetry reading
Assess bowel sounds
Auscultate lung sounds
Determine two touch discrimination in the lower extremities
Correct Answer : A,B,D
A. Assess respiratory rate and rhythm. Changes in breathing pattern may indicate hypoxia, respiratory distress, or metabolic acidosis.
B. Pulse oximetry reading. Measures oxygen saturation, which is critical in assessing oxygenation and ventilation status.
C. Assess bowel sounds. While anxiety and stress can affect the gastrointestinal system, bowel sounds are not directly relevant in this situation.
D. Auscultate lung sounds. Important for identifying wheezing, crackles, or diminished breath sounds, which may indicate bronchospasm, fluid overload, or airway obstruction.
E. Determine two-point discrimination in the lower extremities. This test assesses neurological function, which is not a priority in a client presenting with respiratory distress and anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Stress incontinence. Stress incontinence occurs when intra-abdominal pressure (e.g., sneezing, coughing, laughing) causes urine leakage due to weak pelvic floor muscles or urethral sphincter dysfunction.
B. Reflex incontinence. Reflex incontinence is involuntary urination without warning due to neurological dysfunction (e.g., spinal cord injury, multiple sclerosis), which is not the case here.
C. Urge incontinence. Urge incontinence is a sudden, intense need to urinate, often caused by overactive bladder syndrome or neurological disorders. It is not associated with sneezing.
D. Overflow incontinence. Overflow incontinence occurs when the bladder fails to empty completely, leading to dribbling of urine due to urinary retention (e.g., BPH, diabetic neuropathy).
Correct Answer is D
Explanation
A. Thickened vertebral disks: Aging leads to thinning of intervertebral disks, which contributes to a decrease in height and spinal flexibility.
B. Increased force of isometric contractions: Aging results in decreased muscle strength, not increased force of contractions.
C. Decreased chest width: Aging can lead to a barrel chest appearance due to changes in the thoracic cage, rather than a decrease in width.
D. Decreased muscle mass: Sarcopenia, or the loss of muscle mass with aging, is a common musculoskeletal change that contributes to reduced strength and function.
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