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 A

Explanation

Choice A Reason:
Standing directly in front of the client and ask about any hearing loss is appropriate because the client's behavior of ignoring questions from the nurse and speaking loudly to her son suggests a potential hearing impairment. Standing directly in front of the client allows for better visibility of facial expressions and lip movements, which can aid in communication for individuals with hearing loss. Asking about any hearing loss helps the nurse gather important information to adapt communication strategies effectively.
Choice B Reason:
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests involves conducting hearing tests using a tuning fork to assess for conductive or sensorineural hearing loss. While these tests are valuable for diagnosing hearing impairments, they are typically performed after obtaining a thorough history and initial assessment, including asking about any hearing loss. Therefore, this option is not the first action to take when communication difficulties are observed.
Choice C Reason:
Beginning to orient the client to her surroundings in the hospital room involves providing orientation to the client about her surroundings, which is important for promoting comfort and reducing anxiety, especially in a new environment like a hospital room. However, addressing potential hearing loss is the priority when the client's behavior suggests difficulty in communication. Once hearing impairment is ruled out or addressed, orientation to the surroundings can be initiated.
Choice D Reason:
Performing a mental status exam to assess the client's thought processes involves assessing the client's cognitive function and thought processes, which is important for understanding the client's overall mental status. While assessing mental status is an essential aspect of comprehensive nursing assessment, it may not directly address the observed communication difficulties related to potential hearing impairment. Therefore, addressing potential hearing loss should be the first action to ensure effective communication before proceeding with a mental status exam.

A. Hyperextension and palmar flexion. B. Plantar flexion. C. Forearm pronation. D. Forearm supination.

Correct Answer is A

Explanation

Choice A Reason:
Hyperextension and palmar flexion are correct. Hyperextension involves moving the wrist joint backward, testing its ability to extend beyond its neutral position. Palmar flexion involves moving the wrist joint forward, testing its ability to flex toward the palm. These movements collectively assess the range of motion of the wrist joint in both directions, which is essential for identifying any limitations or pain associated with certain movements. Since the client presents with right wrist pain and ecchymosis, assessing both hyperextension and palmar flexion can help determine if there's any injury or impairment affecting the wrist's mobility.
Choice B Reason:
Plantar flexion is incorrect. Plantar flexion refers to a movement of the foot and ankle, not the wrist. Therefore, instructing the client to perform plantar flexion would not assess the wrist's mobility and is not relevant to the presented scenario of right wrist pain with ecchymosis.
Choice C Reason:
Forearm pronation is incorrect. Forearm pronation involves rotating the forearm so that the palm faces downward. This movement primarily assesses the pronation and supination of the forearm, not the wrist's mobility. Since the client's symptoms are specific to the wrist, assessing forearm pronation would not directly evaluate the wrist's range of motion.
Choice D Reason:
Forearm supination is incorrect. Forearm supination involves rotating the forearm so that the palm faces upward. Similar to forearm pronation, this movement primarily assesses the forearm's mobility, not the wrist's mobility. Therefore, instructing the client to perform forearm supination would not be an appropriate method for assessing the wrist's range of motion in the context of right wrist pain with ecchymosis.

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

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?

Correct Answer is A

Explanation

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?

Correct Answer is A

Explanation

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

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?

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

The nurse continues a neurologic assessment of the cranial nerve XI (Spinal accessory) for a client. Which instruction should the nurse give the client to complete this assessment?

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?