The client's respiratory rate is 9 breaths per minute, and they deny feeling short of breath. The nurse will document this finding as:
Eupnea
Bradypnea
Tachypnea
Dyspnea
The Correct Answer is B
A) Eupnea: Eupnea refers to a normal respiratory rate, typically between 12 to 20 breaths per minute for adults. Given that the client’s respiratory rate is significantly lower than this range, documenting the finding as eupnea would not accurately reflect the client’s condition.
B) Bradypnea: Bradypnea is defined as a slower-than-normal respiratory rate, usually less than 12 breaths per minute. With the client's rate at 9 breaths per minute, this is an example of bradypnea. It is crucial for the nurse to document this finding accurately, even though the client denies feeling short of breath, as it could indicate an underlying issue requiring further assessment.
C) Tachypnea: Tachypnea indicates a faster-than-normal respiratory rate, typically over 20 breaths per minute. Since the client's respiratory rate is low at 9 breaths per minute, labeling it as tachypnea would be incorrect and misleading.
D) Dyspnea: Dyspnea refers to difficulty or discomfort in breathing. Although the client does not report feeling short of breath, it is essential to note that the low respiratory rate could still lead to respiratory distress, but it does not meet the criteria for dyspnea based on the client's self-report. Therefore, documenting this finding as dyspnea would not be appropriate.
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Correct Answer is B
Explanation
A) Muscle strength: While muscle strength can influence gait, it specifically refers to the ability of muscles to exert force against resistance. Assessing muscle strength involves different techniques, such as manual muscle testing, rather than observing arm and leg movements.
B) Gait: The observation that both arms swing freely in alternation with leg swings is a direct assessment of the patient's gait. A normal gait pattern includes coordinated movements of the arms and legs, indicating proper motor function and balance.
C) Alignment: This term refers to the positioning of the body and its parts in relation to one another. While alignment can impact gait, it is not specifically assessed by observing the movement of the arms and legs.
D) Joint function: Joint function assessment typically focuses on the range of motion, stability, and mobility of individual joints. Observing the swing of arms and legs provides insight into overall gait rather than specific joint function.
Correct Answer is D
Explanation
A) Occurs only in the clinical area: Focused assessments can be conducted in various settings, including outpatient clinics, home health visits, and emergency departments. Thus, this statement does not accurately define the difference.
B) Involves all body systems: A focused assessment is specifically targeted and does not involve an evaluation of all body systems. Instead, it concentrates on particular areas of concern, making this statement incorrect.
C) Covers the body from head to toe: This describes a comprehensive assessment rather than a focused one. A comprehensive assessment is thorough and covers the entire body, while a focused assessment zeroes in on specific issues or symptoms.
D) More in depth on specific issues: A focused assessment is designed to gather detailed information about particular health problems or concerns rather than providing a broad overview of the patient’s overall health. This targeted approach allows healthcare providers to identify and address specific needs effectively, making this the correct choice.