The nurse is conducting an assessment of a client that has been admitted to a medical unit in the hospital for treatment of pneumonia. Which action will the nurse take when conducting the respiratory assessment of this client?
Document "impaired oxygenation" on the nursing care plan.
Auscultate the chest for breath sounds.
Collaborate with the client to form goals.
Apply supplemental oxygen by face mask as needed.
The Correct Answer is B
A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.
B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.
C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.
D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Lithotomy: The lithotomy position is primarily used for gynecological exams and procedures, where the client is lying on their back with legs elevated and supported. It is not appropriate for breast examination.
B. Sims: The Sims position, where the client is lying on their side with one knee bent, is typically used for rectal exams and certain types of enemas. It is not suitable for breast examination.
C. Supine: The supine position, where the client lies flat on their back, is the most appropriate for breast examination. This position allows for better palpation and inspection of the breasts and facilitates a thorough examination.
D. Prone: The prone position involves lying face down. This position does not provide access to the breasts and is not used for breast examination.
Correct Answer is C
Explanation
A. Obesity: While obesity can be linked to a negative self-concept, it is not as closely associated with a "skeletal appearance" as anorexia nervosa.
B. Fad dieting: Fad dieting may indicate concerns about body image, but it does not typically lead to a skeletal appearance and may not necessarily be tied to a deeply negative self-concept.
C. Anorexia nervosa: Anorexia nervosa is characterized by extreme weight loss and a skeletal appearance. It is often associated with a severely negative self-concept and distorted body image, where individuals see themselves as overweight even when they are underweight.
D. Eating fast foods: While this can lead to poor nutritional habits and weight issues, it does not typically lead to a skeletal appearance and is not directly associated with a negative self-concept.
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