A client is being treated for an acute exacerbation of asthma. Which assessment finding indicates to the nurse that the goals of treatment are being met?

The nurse observes the client using accessory muscles while breathing.

The client is able to answer questions in full sentences.

Lung auscultation demonstrates diminished breath sounds.

The client appears restless and anxious when resting in bed.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Using accessory muscles while breathing is a sign of respiratory distress and indicates that the client is working harder to breathe. This is not a desired outcome of treatment and suggests that the asthma exacerbation is not under control.

Choice B Reason:

The ability to answer questions in full sentences suggests that the client's airway is not severely obstructed, which is a positive sign of effective asthma treatment. When asthma is well-controlled, individuals should not experience significant shortness of breath that limits their ability to speak.

Choice C Reason:

Diminished breath sounds can be a sign of severe airway obstruction and are not indicative of effective asthma treatment. Ideally, lung auscultation should reveal clear breath sounds without wheezing, indicating good air movement throughout the lungs.

Choice D Reason:

Restlessness and anxiety can be symptoms of hypoxia, a condition where the body or a region of the body is deprived of adequate oxygen supply. This is not a sign of effective asthma treatment and may indicate that the client's asthma is not well-managed.

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Correct Answer is B

Explanation

Choice A Reason
While some medications for hypertension can cause visual side effects, it is not the most immediate concern when a patient reports blurred vision. Medication-related side effects are important to consider, but they typically present consistently rather than intermittently.

Choice B Reason
An ophthalmic examination is crucial for evaluating intermittent blurred vision in a client with hypertension. Hypertension can lead to hypertensive retinopathy, where high blood pressure causes damage to the blood vessels in the retina, potentially resulting in blurred vision or vision loss. An eye exam can help diagnose this condition and prevent further complications.

Choice C Reason
Blurred vision can indeed be associated with hypertension, particularly in severe cases or hypertensive crises. However, it is not considered a 'common' problem but rather a sign of potential end-organ damage, such as hypertensive retinopathy, which requires prompt medical evaluation.

Choice D Reason
The risk of brain tumors is not directly associated with hypertension. While hypertension is a risk factor for certain conditions like stroke, it is not typically linked with an increased risk of brain tumors. This choice might cause unnecessary alarm without a clinical basis.

A. "Excess sodium from hypertension causes direct injury to the arteries, reducing blood flow and causing obstruction." B. "Excess fats in your diet are stored in the lining of the arteries, causing them to constrict." C. "A combination of platelets and fats accumulate, narrowing the artery and reducing blood flow to the extremities." D. "Injury to the arteries causes them to spasm, reducing blood flow to the extremities."

Correct Answer is C

Explanation

Choice A Reason
While hypertension can contribute to the development of PAD, it does not directly cause fats to deposit in the arteries. Hypertension can damage the arterial walls, making them more susceptible to atherosclerosis, but it is not the primary mechanism of PAD development.

Choice B Reason
Excess fats in the diet can contribute to atherosclerosis, which is the accumulation of plaques in the arterial walls. However, the fats do not simply get stored; they combine with other substances, including calcium and inflammatory cells, to form plaques that can restrict blood flow.

Choice C Reason
This statement is the most accurate. PAD is primarily caused by atherosclerosis, which is the buildup of plaques formed by fats, cholesterol, calcium, and other substances in the blood. These plaques can harden and narrow the arteries, leading to reduced blood flow to the extremities. The process can be exacerbated by factors such as smoking, diabetes, and high cholesterol.

Arterial spasms can occur, but they are not the typical cause of chronic PAD. Spasms are more often associated with conditions like Raynaud's phenomenon or can be a response to stress or cold temperatures. PAD is usually a result of progressive atherosclerosis rather than intermittent spasms.

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A client is being treated for an acute exacerbation of asthma. Which assessment finding indicates to the nurse that the goals of treatment are being met?

Nursing Test Bank

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Explanation

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Correct Answer is C

Explanation

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