While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

Explain to the client the possible causes of dyspnea or "shortness of breath."

Ask the client to describe the episodes of dyspnea in more detail.

Document "dyspnea on exertion" in the client's medical record.

Ask the client to perform light exercise and observe the respiratory effort.

Answer and Explanation

The Correct Answer is B

A. Explain to the client the possible causes of dyspnea or "shortness of breath.": While the nurse might eventually explain this, it's premature without more information about the client's specific shortness of breath experience.

B. Ask the client to describe the episodes of dyspnea in more detail: This is the most appropriate next step. Understanding the characteristics, triggers, and severity of the dyspnea will help determine the cause and guide further assessment.

C. Document "dyspnea on exertion" in the client's medical record: The client only reports experiencing shortness of breath "at times," not necessarily with exertion. More details are needed before documenting.

D. Ask the client to perform light exercise and observe the respiratory effort: This could worsen the client's condition if the shortness of breath is severe. Observation during rest provides a safer approach initially.

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Correct Answer is A

Explanation

A. "What were you doing when you first noticed the problem?"

This question helps to identify any specific activities or events that may have triggered the onset of back pain. Understanding the circumstances surrounding the pain can provide valuable information about its potential cause.

B. "Have you taken any medications to relieve the pain?"

While it's important to assess if the adolescent has taken any medications, such as over-the-counter pain relievers, to manage the pain, this question may not be the most immediate priority. It's essential to first gather information about the nature and onset of the pain to guide further assessment and management.

C. "Do you remember ever having this type of pain in the past?"

This question helps to determine if the adolescent has a history of similar back pain episodes. Past episodes of back pain can provide insight into potential underlying conditions or recurrent issues that may be contributing to the current complaint.

D. "Does changing your position make the pain worse?"

This question is crucial in assessing the characteristics of the pain and its response to movement or positional changes. It can help differentiate between musculoskeletal causes of back pain, which may worsen with movement, and other potential causes.

A. Question the client about the frequency of falls in recent months. B. Request to have the client lie as still as possible for the assessment. C. Assist the client with clarifying values about end-of-life care options. D. Ask the client how often episodes of sundowning are experienced.

Correct Answer is A

Explanation

A. Question the client about the frequency of falls in recent months: Falls are a common concern in older adults. Assessing the frequency of falls helps identify potential safety risks and mobility issues. It provides valuable information about the client’s functional status and balance.

B. Request to have the client lie as still as possible for the assessment: While assessing functional status, it is essential to observe the client’s mobility and ability to perform activities of daily living (ADLs). Having the client lie still would not provide relevant information about their functional abilities.

C. Assist the client with clarifying values about end-of-life care options: While discussing end-of-life care is important, it is not directly related to assessing functional status. This action is beyond the scope of a functional assessment.

D. Ask the client how often episodes of sundowning are experienced: Sundowning refers to increased confusion, agitation, or behavioural changes in older adults during the late afternoon or evening. While relevant to overall well-being, it is not specifically related to functional assessment.

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While the nurse is obtaining a health history, the client reports experiencing shortness of breath at times. The nurse determines that the client's respirations are regular and deep and respiratory rate is 14 breaths/minute. Which is the best nursing action?

Nursing Test Bank

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