Nokea
The ED nurse is assessing the respiratory function of a teenage girl who presented with acute shortness of breath. Auscultation reveals continuous wheezes during inspiration and expiration. This finding is most suggestive of what?
- A. Pleurisy
- B. Emphysema
- C. Asthma
- D. Pneumonia
Correct Answer: C
Rationale: The continuous wheezes heard on auscultation during both inspiration and expiration in a teenage girl with acute shortness of breath are highly suggestive of asthma. Asthma is characterized by airway inflammation and bronchoconstriction, leading to wheezing on both inspiration and expiration. Other choices like pleurisy typically present with sharp chest pain worsened by breathing, emphysema with decreased breath sounds and barrel chest, and pneumonia with crackles and possibly fever.
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A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding?
- A. Are you taking any medications or herbal supplements?
- B. Do you have any chronic breathing problems?
- C. How often do you perform aerobic exercise?
- D. What is your occupation and what are your hobbies?
Correct Answer: B
Rationale: The correct answer is B: Do you have any chronic breathing problems? This question is appropriate because equal AP and lateral chest diameters could indicate barrel chest, which is often associated with chronic obstructive pulmonary disease (COPD) or other chronic breathing problems. Asking about chronic breathing problems can help the nurse further assess the client's respiratory health.
Incorrect answers:
A: Are you taking any medications or herbal supplements? This question is not directly related to the observed chest diameter findings.
C: How often do you perform aerobic exercise? This question is not relevant to the physical assessment findings and does not address the potential respiratory issue.
D: What is your occupation and what are your hobbies? This question does not directly address the equal AP and lateral chest diameters and does not help in assessing the respiratory status of the client.
You are providing care for a client with recently diagnosed asthma. What key points will you be sure to include in your teaching plan for this client? (Choose all that apply.)
- A. Avoid potential environmental asthma triggers such as smoke.
- B. Use inhaler 30 minutes before exercising to prevent bronchospasm.
- C. Wash all bedding in cold water to reduce and destroy dust mites.
- D. Be sure to get at least 8 hours of rest and sleep every night.
Correct Answer: D
Rationale: The correct answer includes A, B, and D. Avoiding triggers (A), using inhalers before exercise (B), and ensuring adequate rest (D) are important for asthma management. Washing bedding in cold water (C) is ineffective for destroying dust mites; hot water is required.
A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?
- A. Document the findings.
- B. Administer oxygen therapy.
- C. Position the client in high-Fowlers position.
- D. Administer prescribed albuterol.
Correct Answer: A
Rationale: The correct answer is A: Document the findings. The nurse should first document the assessment findings to establish a baseline and communicate the abnormal sound to the healthcare team for further evaluation. This is crucial for accurate diagnosis and treatment planning. Administering oxygen therapy (B) may be needed depending on the client's oxygen saturation but is not the priority in this situation. Positioning the client in high-Fowlers position (C) may help with breathing but does not address the underlying cause of the abnormal sound. Administering albuterol (D) may be indicated for bronchospasm but should not be done without understanding the cause of the harsh hollow sound first.
While assisting a patient with intermittent asthma to identify specific triggers of asthma, what should the nurse explain?
- A. a. Food and drug allergies do not manifest in respiratory symptoms.
- B. b. Exercise-induced asthma is seen only in individuals with sensitivity to cold air.
- C. c. Asthma attacks are psychogenic in origin and can be controlled with relaxation techniques.
- D. d. Viral upper respiratory infections are a common precipitating factor in acute asthma attacks.
Correct Answer: d
Rationale: The correct answer is D because viral upper respiratory infections are a common precipitating factor in acute asthma attacks. This is important information for the patient to understand in order to help identify triggers and manage their asthma effectively. Viral infections can exacerbate asthma symptoms, so recognizing this connection can aid in prevention and treatment.
Smoking has been shown to cause
- A. bronchitis.
- B. emphysema.
- C. lung cancer.
- D. all of the above
Correct Answer: D
Rationale: Smoking causes bronchitis due to inflammation of bronchial tubes, emphysema by damaging air sacs in lungs, and lung cancer from carcinogens. Therefore, "D: all of the above" is correct as smoking leads to all these respiratory health issues. Choices A, B, and C are incorrect as smoking is linked to all three conditions.