A nurse in the Emergency Department (ED) is caring for a client who is having acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?(Select all that apply)

Premature Ventricular Contractions (PVC's)

Respiratory Rate of 14 / min

Circumoral cyanosis

Retraction of sternal muscles

SpO2 95%

Answer and Explanation

Correct Answer : C,D

A.   Premature Ventricular Contractions (PVC's) (A) are related to cardiac activity and not directly indicative of respiratory function.
B.   A respiratory rate of 14 breaths per minute is within the normal range for adults (12-20 breaths per minute). Therefore, this finding does not indicate a decline in respiratory status.
C.   Circumoral cyanosis, which refers to a bluish discoloration around the mouth, indicates hypoxia and is a sign of deteriorating respiratory status. It suggests that the body is not getting enough oxygen, which is critical to monitor in an asthma attack.
D.   Retractions, especially of the sternal muscles, are a sign of increased work of breathing and can indicate severe respiratory distress. This finding suggests that the patient is struggling to breathe effectively, indicating a decline in respiratory status.
E.   An SpO2 of 95% is generally considered acceptable, especially in patients with asthma, as normal oxygen saturation levels typically range from 95% to 100%. While it is at the lower end of normal, it does not indicate an immediate decline in respiratory status.

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Correct Answer is B

Explanation

A. Osteoarthritis (OA) typically presents with joint pain and stiffness, but it is usually unilateral and does not cause the same types of deformities seen in RA. OA also tends to develop over time without the systemic symptoms associated with RA.
B. The combination of bilateral pain and morning stiffness in the hands, along with the presence of large nodules (likely rheumatoid nodules), swan-neck deformities, and ulnar deviation, is characteristic of rheumatoid arthritis (RA). RA is an autoimmune disorder that affects joints symmetrically and commonly leads to these specific deformities.
C. Lupus arthritis can cause joint pain and swelling, but it is often accompanied by other systemic symptoms like skin rashes (butterfly rash), fatigue, and organ involvement. The specific deformities noted (swan-neck and ulnar deviation) are more closely aligned with RA than lupus.
D. Gout is characterized by sudden, severe attacks of pain, often in the big toe or foot, and is caused by the deposition of urate crystals in the joints. It does not typically present with the deformities or patterns seen in the described patient.

A. Leukocytosis B. Left shift C. Erythrocytosis D. Neutropenia

Correct Answer is A

Explanation

A. Leukocytosis refers to an elevated white blood cell (WBC) count, typically above the normal range (approximately 4,000 to 10,000 WBCs per microliter of blood). A count of 22,000 indicates leukocytosis, which may be due to infection, inflammation, stress, or other conditions.
B. A left shift refers to an increase in immature white blood cells, particularly neutrophil precursors, in the bloodstream. It often indicates an acute infection or inflammatory response. While the WBC count of 22,000 may suggest a left shift, it does not confirm it without further analysis of the differential count of the WBCs.
C. Erythrocytosis is an increase in red blood cells (RBCs), not white blood cells. Therefore, this option is incorrect. A high WBC count does not indicate changes in red blood cell levels.
D. Neutropenia refers to a decreased number of neutrophils, which are a type of white blood cell. Given the WBC count of 22,000, neutropenia is not applicable and is therefore incorrect.

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A nurse in the Emergency Department (ED) is caring for a client who is having acute asthma attack. Which of the following assessments indicates that the respiratory status is declining?(Select all that apply)

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is caring for a client who has a WBC count of 22,000. The nurse should conclude that the client has which of the following?

Correct Answer is A

Explanation

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