Nokea
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
- A. Loud wheezing
- B. Wheezing on expiration
- C. Noticeably diminished breath sounds
- D. Increased displays of emotional apprehension
Correct Answer: C
Rationale: Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced.
You may also like to solve these questions
The nurse creates a postoperative plan of care for a client undergoing an arthroscopy. The nurse should include which priority action in the plan?
- A. Monitor intake and output.
- B. Assess the tissue at the surgical site.
- C. Monitor the area for numbness or tingling.
- D. Assess the complete blood cell count results.
Correct Answer: C
Rationale: Arthroscopy provides an endoscopic examination of the joint and is used to diagnose and treat acute and chronic disorders of the joint. The priority nursing action is to monitor the affected area for numbness or tingling, which could indicate neurovascular compromise.
A child is admitted to the pediatric unit with a diagnosis of celiac disease. Based on this diagnosis, the nurse expects that the child's stools will have which characteristic?
- A. Malodorous
- B. Dark in color
- C. Unusually hard
- D. Abnormally small in amount
Correct Answer: A
Rationale: Celiac disease is a disorder characterized by intolerance to gluten, leading to malabsorption and gastrointestinal symptoms. The stools of a child with celiac disease are typically malodorous, bulky, frothy, and pale due to steatorrhea (excess fat in the stool) caused by impaired nutrient absorption. Dark-colored stools, hard stools, or small amounts are not characteristic of celiac disease.
A client newly diagnosed with polycystic kidney disease asks the nurse to explain again what the most serious complication of the disorder might be. The nurse will provide the client with information concerning which condition?
- A. Diabetes insipidus
- B. End-stage renal disease (ESRD)
- C. Chronic urinary tract infection (UTI)
- D. Syndrome of inappropriate antidiuretic hormone (SIADH) secretion
Correct Answer: B
Rationale: In polycystic kidney disease, cystic formation and hypertrophy of the kidneys occur. The most serious complication of polycystic kidney disease is ESRD, which is managed with dialysis or transplant. There is no reliable way to predict who will ultimately progress to ESRD. Chronic UTIs are the most common complication because of the altered anatomy of the kidney and from development of resistant strains of bacteria. Diabetes insipidus and SIADH secretion are unrelated disorders.
A client has been admitted with a diagnosis of acute glomerulonephritis. During history taking, the nurse should ask the client about a recent history of which event?
- A. Bleeding ulcer
- B. Myocardial infarction
- C. Deep vein thrombosis
- D. Streptococcal infection
Correct Answer: D
Rationale: The predominant cause of acute glomerulonephritis is infection with beta-hemolytic Streptococcus 3 weeks before the onset of symptoms. In addition to bacteria, other infectious agents that could trigger the disorder include viruses, fungi, and parasites. Bleeding ulcer, myocardial infarction, and deep vein thrombosis are not precipitating causes.
A client with a known history of panic disorder comes to the emergency department and states to the nurse, 'Please help me. I think I'm having a heart attack.' What is the priority nursing action?
- A. Assess the client's vital signs.
- B. Encourage the client to use relaxation techniques.
- C. Identify the manifestations related to the panic disorder.
- D. Determine what the client's activity involved when the pain started.
Correct Answer: A
Rationale: Clients with a panic disorder can experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder for these signs and symptoms. Although options 2, 3, and 4 may be appropriate at some point in the care of the client, they are not the priority.