Nokea
History & Physical
Initial Assessment Findings
Chief Complaint: Acute asthma attack after jogging; worsened by outdoor activity and exercise.
Current Treatment: Used rescue inhaler three times, expired inhaler, worried about effectiveness.
Patient Data
Exhibits
The nurse has identified the priority problem for the client and now must determine proper care interventions.
Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
- A. Administer medications as ordered.
- B. Provide client teaching.
- C. Place the client in Trendelenburg position
- D. Ask the client for a list of current medications.
- E. Notify the healthcare provider of the client's need for intubation
- F. Apply oxygen via nasal cannula
Correct Answer: A,B,D,F
Rationale: Administering medications and oxygen (F) address the acute asthma attack. Obtaining a medication list ensures safe treatment, and teaching prevents future exacerbations. Trendelenburg position is inappropriate, and intubation is premature without further assessment.
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Patient Data
History and Physical
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse reviews the client's history of the presenting illness in the electronic medical record.
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
- A. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
- B. The client reports that symptoms seem worse when outdoors and when exercising.
Correct Answer: A,B
Rationale: The ineffective use of the rescue inhaler indicates a severe asthma attack requiring intervention, and worsening symptoms with exercise suggest environmental triggers needing management.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Bradycardia and constipation.
- B. Lethargy and lack of appetite.
- C. Muscle cramping and dry, flushed skin.
- D. Palpitations and shortness of breath.
Correct Answer: D
Rationale: Palpitations and shortness of breath indicate hyperthyroidism from excessive levothyroxine, requiring dosage adjustment.
A client with a renal calculus reports severe right flank pain, nausea, and vomiting. Which nursing problem has the highest priority?
- A. Impaired renal function related to pain.
- B. Acute pain related to renal calculus.
- C. Risk for aspiration related to vomiting.
- D. Nutritional deficit related to nausea.
Correct Answer: C
Rationale: Risk for aspiration is the highest priority due to the immediate threat of airway obstruction from vomiting.
The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with cardiovascular disease. Which outcome should the nurse include in the plan of care for this client?
- A. The client's blood pressure reading will be less than 160/90 mm Hg.
- B. The client's daily blood pressure will be less than 140/80 mm Hg this month.
- C. The client's family will repeat signs and symptoms about the disease.
- D. The nurse will encourage the client to walk thirty minutes every day.
Correct Answer: B
Rationale: A blood pressure goal of less than 140/80 mm Hg is specific and aligns with cardiovascular health targets, addressing blurred vision linked to hypertension.
A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?
- A. Hydromorphone.
- B. Morphine.
- C. Oxycodone.
- D. Fentanyl.
Correct Answer: B
Rationale: Morphine relieves pain, reduces anxiety, and provides vasodilation in myocardial infarction, improving cardiac workload.