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 A

Explanation

Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis).Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.

A. Black tarry stools. B. A cloudy discharge. C. An overactive bladder D. A weak urinary stream.

Correct Answer is D

Explanation

Choice A Reason:
Black tarry stools are inappropriate. Black tarry stools may indicate gastrointestinal bleeding, which is not directly related to the client's symptoms of suprapubic tenderness and pressure after urination. While it's important to consider other potential health issues, such as gastrointestinal bleeding, it may not be directly relevant to the client's current urinary symptoms.
Choice B Reason:
A cloudy discharge is inappropriate. A cloudy discharge may suggest an infection or inflammation in the urinary tract, but it is not specifically associated with the symptoms described by the client (suprapubic tenderness and pressure after urination). While urinary tract infections (UTIs) can occur in older adults, they may present with symptoms such as urinary urgency, frequency, dysuria, and hematuria, rather than suprapubic tenderness and pressure after urination.
Choice C Reason:
An overactive bladder is inappropriate. While overactive bladder can cause urinary urgency and frequency, it is less likely to present with suprapubic tenderness and pressure after urination. Overactive bladder is characterized by sudden, involuntary contractions of the bladder muscles, leading to a frequent and urgent need to urinate. It may not directly explain the client's symptoms of suprapubic tenderness and pressure after urination, which are more suggestive of urinary obstruction due to BPH.
Choice D Reason:
A weak urinary stream is appropriate. Benign prostatic hyperplasia (BPH) is a common condition in older men characterized by noncancerous enlargement of the prostate gland, which can lead to compression of the urethra and urinary symptoms. A weak urinary stream is a classic symptom of BPH due to the obstruction caused by the enlarged prostate gland, which interferes with the normal flow of urine. Therefore, the nurse should expect a weak urinary stream as an additional finding during the client interview, which is consistent with the suspected diagnosis of BPH.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, a client with a temperature of 103° F (39.4° C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

The nurse is examining the abdomen of an older male client who expresses suprapubic tenderness on palpation. The client states that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?

Correct Answer is D

Explanation

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