When entering a client's room, the nurse observes that the client is using pursed-lip breathing. It is most important for the nurse to monitor the client for which problem?

Syncope.

Acute pain.

Tetany.

Dyspnea.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Syncope is incorrect. Syncope, or fainting, can occur in individuals experiencing severe respiratory distress or hypoxia. Pursed-lip breathing is often used as a technique to manage dyspnea and improve oxygenation, which can help prevent syncope by ensuring adequate ventilation and oxygen delivery to the body's tissues. However, syncope is not the primary concern associated with the observation of pursed-lip breathing; instead, it is a potential consequence of inadequate oxygenation.
Choice B Reason:
Acute pain is not directly related to the observation of pursed-lip breathing. Pursed-lip breathing is a technique used to manage dyspnea and improve ventilation efficiency in individuals with respiratory conditions such as chronic obstructive pulmonary disease (COPD) or asthma exacerbation. While pain can exacerbate respiratory distress in some cases, the primary focus when observing pursed-lip breathing is to assess and address respiratory status rather than pain management.
Choice C Reason:
Tetany is incorrect. Tetany, characterized by muscle spasms due to low calcium levels, is not directly associated with the observation of pursed-lip breathing. Pursed-lip breathing is a respiratory technique used to manage dyspnea and improve ventilation in individuals with respiratory conditions such as COPD or asthma. While respiratory distress can lead to various physiological responses, tetany is not a typical manifestation observed in individuals using pursed-lip breathing.
Choice D Reason:
Dyspnea is correct. Pursed-lip breathing is a technique often used by individuals with respiratory conditions to relieve shortness of breath and improve breathing efficiency. The primary reason for using pursed-lip breathing is to help alleviate dyspnea, or difficulty breathing, by promoting more effective exhalation and preventing airway collapse during expiration. Monitoring for dyspnea is crucial in this situation to assess the client's respiratory status, including the severity of breathing difficulty and any associated symptoms, and to guide further interventions to address the underlying cause of dyspnea. While syncope (fainting), acute pain, and tetany (muscle spasms due to low calcium levels) are potential concerns in certain clinical contexts, they are not directly associated with the observation of pursed-lip breathing. Therefore, dyspnea is the most relevant problem for the nurse to monitor in this scenario.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A Reason:
Fluid volume excess is incorrect. Fluid volume excess refers to an overabundance of fluid in the body, leading to symptoms such as edema, weight gain, and hypertension. However, a BMI of 14 kg/m^2 indicates underweight, not fluid volume excess. Therefore, this choice is incorrect.
Choice B Reason:
Unbalanced nutrition, less than body needs is correct. A BMI of less than 18.5 indicates underweight according to the provided reference range. Underweight individuals often do not consume enough nutrients to meet their body's needs, leading to potential nutritional deficiencies. Therefore, the nursing problem of "Unbalanced nutrition, less than body needs" is appropriate for addressing the client's low BMI.
Choice C Reason:
Unbalanced nutrition, greater than body needs is incorrect. This choice would be more applicable if the client's BMI indicated overweight or obesity, as it suggests an excess intake of nutrients relative to the body's needs. However, a BMI of 14 kg/m^2 indicates underweight, not excess weight. Therefore, this choice is incorrect.
Choice D Reason:
Fluid volume deficit is incorrect. Fluid volume deficit refers to a decreased amount of fluid in the body, leading to symptoms such as dehydration, decreased urine output, and hypotension. However, a low BMI does not necessarily indicate fluid volume deficit; it primarily reflects undernutrition. Therefore, this choice is incorrect.

A. Chronic pancreatitis. B. Peptic ulcer disease (PUD). C. Esophagitis. D. Gastroesophageal reflux (GERD).

Correct Answer is B

Explanation

Choice A Reason:
Chronic pancreatitis is incorrect. Chronic pancreatitis typically presents with persistent, dull abdominal pain that may radiate to the back, often aggravated by eating rather than relieved by it. The pain associated with chronic pancreatitis is not typically described as gnawing or relieved by eating.
Choice B Reason:
Peptic ulcer disease (PUD) is correct. Peptic ulcer disease involves the development of open sores (ulcers) in the lining of the stomach (gastric ulcers) or the upper part of the small intestine (duodenal ulcers). The pain associated with PUD typically occurs in the epigastric region (upper abdomen) and can be described as gnawing, burning, or dull. The pain tends to worsen when the stomach is empty (hunger pains) and is relieved by eating or taking antacids. These symptoms are due to the increase in gastric acid secretion, which exacerbates the ulcer's irritation when the stomach is empty and is neutralized when food buffers the acid. Therefore, the presentation described is consistent with peptic ulcer disease (PUD).
Choice C Reason:
Esophagitis is incorrect. Esophagitis is inflammation of the esophagus and may present with symptoms such as heartburn, difficulty swallowing, or chest pain behind the breastbone. However, the symptoms described, particularly the worsening of pain when hungry and improvement after eating, are not typical of esophagitis.
Choice D Reason:
Gastroesophageal reflux (GERD) is incorrect. While gastroesophageal reflux disease (GERD) can cause epigastric discomfort or heartburn, the symptoms described in the scenario are more indicative of pain related to hunger and relief after eating, which is more characteristic of peptic ulcer disease (PUD). Additionally, GERD symptoms are typically worsened by eating, lying down, or bending over, rather than improved.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

When entering a client's room, the nurse observes that the client is using pursed-lip breathing. It is most important for the nurse to monitor the client for which problem?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

Correct Answer is B

Explanation

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?

A client is seen in the emergent care clinic for right wrist pain with a pattern of ecchymosis observed on the wrist. Which motion should the nurse instruct the client to perform to assess the wrist mobility?

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

A client is being evaluated for environmental allergies. While examining the client's nasal passage, which finding suggests to the nurse that the client is experiencing allergic rhinitis?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

While interviewing a newly admitted older female client, the nurse observes that the client ignores questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?