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 ["A","B","D"]
Explanation
Choice A reason:
Being free of chest pain and dyspnea is a significant indicator of successful nursing intervention in a sickle cell crisis. Chest pain and dyspnea can occur due to acute chest syndrome, a life-threatening complication of sickle cell disease characterized by vaso-occlusion in the pulmonary microcirculation. Effective pain management and oxygen therapy can alleviate these symptoms, reflecting improved respiratory function and gas exchange.
Choice B reason:
Educating the client on the importance of increasing fluid intake is crucial in managing sickle cell crisis. Adequate hydration helps to reduce blood viscosity and prevent sickling of red blood cells, which can lead to vaso-occlusive episodes. When a client verbalizes understanding and the importance of hydration, it demonstrates the effectiveness of patient education and the client's engagement in self-care.
Choice C reason:
While increasing aerobic exercises may promote endurance, it is not typically a short-term outcome measure for a sickle cell crisis. Exercise must be approached with caution in these clients, as it can increase the risk of a vaso-occlusive crisis due to dehydration and increased oxygen demand during a sickle cell crisis.
Choice D reason:
Control of acute pain to a level of 3 on a standard pain scale indicates successful pain management, a primary goal in the treatment of sickle cell crisis. Pain in sickle cell crisis is due to ischemia from obstructed blood flow by sickled cells. Effective analgesic administration and pain management strategies are essential to achieve this outcome.
Choice E reason:
A leukocyte count of 18,000/mm³ is above the normal range (4,500 to 11,000/mm³) and may indicate an infection or inflammation, which are common complications of sickle cell disease. However, this is not a direct outcome of nursing interventions aimed at managing a sickle cell crisis and thus is not a correct choice.
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Stopping NSAIDs is crucial for clients with PUD because NSAIDs can cause injury to the lining of the stomach or intestine, making it more vulnerable to damage from stomach acid. This can lead to the development or exacerbation of ulcers.
Choice B Reason:
Continuing aspirin may not be advisable for clients with PUD, as aspirin is an NSAID and can contribute to the development of peptic ulcers by inhibiting prostaglandin synthesis, reducing the protective mucosal layer, and increasing susceptibility to injury.
Choice C Reason:
Limiting caffeine is recommended for clients with PUD. Caffeine stimulates gastric acid secretion, which can exacerbate ulcer symptoms and impede the healing process.
Choice D Reason:
Avoiding alcohol is advised for clients with PUD. While there is mixed evidence on alcohol directly causing stomach ulcers, heavy alcohol consumption is considered a risk factor for developing stomach ulcers and can worsen the symptoms of existing ulcers.
Choice E Reason:
Eating large meals is not recommended for clients with PUD. It is better to eat smaller, more frequent meals to avoid overfilling the stomach and increasing gastric pressure, which can exacerbate symptoms.
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