To assess a client's pupillary reaction to accommodation, what action should the nurse take?

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.

Choice A Reason:
An adult male presents with fears that he has "lung cancer." Is appropriate. This choice accurately captures the client's expressed fear of having lung cancer. However, it lacks specificity regarding the duration of symptoms (six weeks) and the nature of the symptom (dry cough). Therefore, while it acknowledges the client's concern, it does not provide comprehensive documentation of the client's reported symptoms.
Choice B Reason:
This option accurately captures the client's primary concern, which is the persistent dry cough lasting for six weeks. It avoids assuming a diagnosis (such as lung cancer) and instead focuses on the client's reported symptom. This type of documentation allows for an objective record of the client's statement while avoiding speculation about specific diagnoses. It also provides important information that can guide further assessment and diagnostic evaluation by healthcare providers.
Choice C Reason:
This option documents the client's expressed concern about having symptoms consistent with lung cancer for the past six weeks. While it accurately reflects the client's fear, it may lead to premature assumptions about the diagnosis before a thorough assessment and diagnostic workup are conducted. It's important for documentation to focus on the client's reported symptoms rather than presumptive diagnoses to maintain objectivity and guide appropriate evaluation and management..
Choice D Reason:
Presents with a hacking non-productive cough of 6 weeks duration. This choice accurately describes the client's reported symptom of a "hacking non-productive cough" and includes the duration of the symptom (six weeks). However, it does not explicitly mention the client's expressed fear of having lung cancer, which is an important aspect of the client's presentation that should be documented. Additionally, the term "hacking" may not fully capture the severity or character of the client's reported cough, as the client described it as "body-wracking." Therefore, while it provides some relevant information, it does not fully capture the client's concerns and presentation.