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 D

Explanation

A. Vaginal discharge, presence of genital warts, abdominal tenderness: While assessing for vaginal discharge and genital warts is important, they are not directly related to the menstrual irregularity described by the client. Abdominal tenderness may be relevant but is not the priority.

B. Urinary frequency, unsteady gait, dental enamel erosion: These symptoms are not specifically associated with missed periods. They may indicate other health issues, but they do not address the primary concern.

C. Breast tenderness, tremors, high blood pressure: Breast tenderness can be related to hormonal changes and menstrual irregularities. Tremors and high blood pressure are less likely to be directly connected to missed periods but should still be assessed.

D. Body weight, hirsutism, thyroid enlargement: Hirsutism (excessive hair growth) and thyroid enlargement (goiter) can be associated with hormonal imbalances, including conditions affecting the menstrual cycle. Assessing body weight is also relevant.

A. Kyphosis. B. Barrel chest. C. Lordosis. D. Pectus excavatum.

Correct Answer is A

Explanation

A. Kyphosis: A rounding of the upper back, causing a hunchback appearance. While it can also be caused by other conditions, a mild kyphosis is a common finding in older adults due to weakening muscles and spinal compression.

B. Barrel chest: This refers to a chest that is fixed in an outward position, often caused by chronic obstructive pulmonary disease (COPD) or other lung conditions.

C. Lordosis: An exaggerated inward curve of the lower back, which is not a typical feature of normal aging.

D. Pectus excavatum: A sunken appearance of the chest wall, usually a congenital condition present from birth.

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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?

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Correct Answer is D

Explanation

Which assessment finding of an older adult client should the nurse associate with normal aging?

Correct Answer is A

Explanation

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