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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
A blood glucose level of 80 mg/dL before eating falls within the normal fasting blood glucose range, which is between 70 mg/dL to 110 mg/dL. Therefore, this finding is not a priority concern for a client taking prednisone.
Choice B Reason:
Gaining 5 pounds over 7 months is not typically a priority concern unless it is sudden or unexplained. Prednisone can cause fluid retention and weight gain as a common side effect, but this gradual weight change does not indicate an immediate health risk.
Choice C Reason:
Waking up with a fever is a priority finding as it may indicate an infection. Patients on prednisone are at increased risk of infections due to its immunosuppressive effects¹. Fever could also signify an exacerbation of inflammatory bowel disease or other complications.
Choice D Reason:
While insomnia is a common side effect of prednisone and can impact quality of life, it is not typically a priority over signs that could indicate infection or exacerbation of the underlying condition
Correct Answer is B
Explanation
Choice A Reason:
The statement "Forget him. There are other fish in the sea." minimizes the client's feelings and does not acknowledge the emotional pain they are experiencing. It is a cliché that can come across as dismissive rather than empathetic.
Choice B Reason:
"You must have been very upset to do what you did." This statement acknowledges the client's distress and does not judge their actions. It reflects an understanding of the depth of their emotional pain, which is a key component of empathy.
Choice C Reason:
"Don't worry, you'll get over him in time." While this statement may be intended to provide reassurance, it does not address the immediate emotional state of the client. It could be perceived as brushing aside their current feelings.
Choice D Reason:
"Why do you think your boyfriend broke up with you?" This question could be seen as probing for information rather than offering support. It might imply that the client is at fault for the breakup, which is not an empathetic approach.
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