During the admission assessment, a male client admitted with chest pain states he has no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Observe for jugular vein distention while the client is flat in bed.

Measure the client's blood pressure when he is lying and standing.

Ask the client how many pillows he sleeps on at night.

Auscultate the client's breath sounds while he is supine.

Answer and Explanation

The Correct Answer is C

Choice A Reason:
Observing for jugular vein distention while the client is flat in bed is incorrect because jugular vein distention is not directly related to orthopnea. Jugular vein distention may indicate increased central venous pressure, which can occur in conditions such as heart failure, but it is not specific to orthopnea, which is difficulty breathing while lying flat.
Choice B Reason:
Measuring the client's blood pressure when he is lying and standing is incorrect because measuring blood pressure in different positions (lying and standing) is used to assess for orthostatic hypotension, not orthopnea. Orthostatic hypotension refers to a drop-in blood pressure upon standing and is not directly related to difficulty breathing while lying flat.
Choice C Reason:
Asking the client how many pillows he sleeps on at night is correct because orthopnea is characterized by difficulty breathing while lying flat, often relieved by sitting up or propping oneself with pillows. Asking the client how many pillows he sleeps on at night provides valuable information about his sleeping position and potential orthopnea. Clients with orthopnea often need to sleep in a semi-upright position or with multiple pillows to alleviate breathing difficulties.
Choice D Reason:
Auscultating the client's breath sounds while he is supine is incorrect because auscultating the client's breath sounds while he is supine may provide information about lung sounds, but it does not specifically assess for orthopnea. Orthopnea refers to difficulty breathing while lying flat, and the assessment of breath sounds may not directly indicate this condition.

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Correct Answer is C

Explanation

Choice A Reason:
Giving the client an object to hold is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While providing an object to hold may engage the muscles, it does not specifically target the muscles involved in arm flexion, which are primarily the biceps brachii and brachialis muscles. Therefore, it may not accurately assess muscle strength during arm flexion.
Choice B Reason:
Instructing the client to close his eyes is not the most appropriate action before asking the client to flex his arms to assess muscle strength. Instructing the client to close his eyes primarily tests proprioception and balance rather than muscle strength. While proprioception is an important aspect of overall neurological function, it is not directly related to assessing muscle strength during arm flexion.
Choice C Reason:
Applying resistance to the client's arms is the most appropriate action before asking the client to flex his arms to assess muscle strength. Applying resistance to the client's arms during flexion allows the nurse to evaluate the client's ability to generate force against resistance, providing a more accurate assessment of muscle strength in the biceps brachii and brachialis muscles.
Choice D Reason:
Palpating the client's muscle tone is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While palpating muscle tone is important for assessing muscle integrity, it does not directly evaluate muscle strength during arm flexion. Muscle tone refers to the resting tension in a muscle and may not accurately reflect muscle strength during active movement.

A. Assess conjunctival sacs of lower lids for pallor. B. Observe the client's urine for dark orange color. C. Examine client's sclera for icterus. D. Review recent serum bilirubin levels.

Correct Answer is C

Explanation

Choice A Reason:
Assessing conjunctival sacs of lower lids for pallor is incorrect. Pallor of the conjunctival sacs, or inner eyelids, may indicate anemia or decreased blood flow. While it can be a sign of various health conditions, it is not specific to jaundice. Jaundice is characterized by yellowing of the skin and sclerae (the white part of the eyes) due to elevated bilirubin levels in the blood, so assessing for pallor would not directly confirm jaundice.
Choice B Reason:
Observing the client's urine for dark orange color is incorrect. Dark orange urine may indicate concentrated urine or dehydration, but it is not specific to jaundice. Jaundice primarily manifests as yellowing of the skin and sclerae due to elevated bilirubin levels, rather than a change in urine color. While changes in urine color may occur in certain liver conditions, such as obstructive jaundice, it is not the most direct or reliable method to confirm jaundice.
Choice C Reason:
Examining client's sclera for icterus is correct. Icterus, or yellowing of the sclerae (the white part of the eyes), is a classic sign of jaundice. Elevated levels of bilirubin in the blood lead to the yellow discoloration of the sclerae, providing a direct visual confirmation of jaundice. Examining the sclerae for icterus is a quick and reliable method to confirm jaundice during a physical assessment.
Choice D Reason:
Reviewing recent serum bilirubin levels is incorrect. Reviewing recent serum bilirubin levels can provide objective data on bilirubin levels in the blood, which may support the diagnosis of jaundice. Elevated serum bilirubin levels are characteristic of jaundice. While this option provides valuable information, it may not be immediately available during a physical assessment and does not directly confirm jaundice visually, unlike examining the sclerae for icterus.

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