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 A
Explanation
A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.
B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.
C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.
D) Impaired cognitive reasoning: Guillain-Barré syndrome primarily affects the peripheral nervous system and does not usually impact cognitive function. Patients typically maintain full cognitive abilities, so the nurse should not anticipate findings
Correct Answer is A
Explanation
A) Crepitus: This is the correct term to document the grating sound heard when a joint is moved. Crepitus can indicate issues such as the presence of air in the joint, cartilage degeneration, or other pathologies. Using this specific term provides clarity to the medical record and helps other healthcare providers understand the nature of the joint's condition.
B) Positive joint sounds: This phrase is less specific and does not adequately describe the type of sound noted during the assessment. It may also lead to ambiguity, as it lacks the medical precision that crepitus provides.
C) Grating and popping: While this description conveys what the nurse observed, it is not a standardized medical term. Precise documentation is essential in medical records, and using non-standard language can lead to confusion.
D) Crackles: Typically associated with respiratory assessments, crackles refer to sounds heard in the lungs and are not applicable to joint examinations. Therefore, this term would be inappropriate for documenting findings related to joint movement.