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Exhibits

The nurse reviews the client's history of the presenting illness in the electronic medical record. Highlight the pieces of key subjective data which indicate the client is in need of health interventions.

A 34-year-old male client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park. The client is able to answer questions every few words to catch his breath. He reports using his rescue inhaler three times, but he couldn't catch his breath. He reports that his symptoms are worse when outdoors and when exercising, and episodes like this make him extremely nervous. He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working.

an asthma attack that began after jogging through a local park

able to answer questions every few words to catch his breath

reports using his rescue inhaler three times, but he couldn't catch his breath

symptoms are worse when outdoors

episodes like this make him extremely nervous

came to the ED today because he noticed his inhaler was expired

Answer and Explanation

The Correct Answer is ["B","C","F"]

Rationale for correct answers:

"The client is able to answer questions every few words to catch his breath."
- Indicates severe shortness of breath, which requires immediate medical attention.
"He reports using his rescue inhaler three times, but he couldn't catch his breath."
- Demonstrates that his asthma attack is not responding to usual interventions, indicating the need for additional or advanced treatment.
"He says that it has been a couple of months since his last asthma attack, and he came to the ED today because he noticed his inhaler was expired and was worried the medication was not working."
- Highlights a lapse in medication management (expired inhaler), suggesting the need for health education and prescription renewal.

Rationale for incorrect answers:

"Episodes like this make him extremely nervous."
- While anxiety is relevant, it is a secondary issue compared to the physiological needs in this situation.
"The client presents to the emergency department (ED) for an asthma attack that began after jogging through a local park."
- The activity triggering the attack (jogging) is not an immediate factor needing intervention but rather an avoidable trigger to address long-term.
"He reports that his symptoms are worse when outdoors and when exercising."
- While important for identifying triggers, this is not an immediate priority for intervention in the emergency setting.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Administering a PRN dose of an antispasmodic agent can help relieve bladder spasms that often occur after TURP, but it does not address the immediate issue of blood clots blocking the drainage tubing. The primary concern is to ensure the patency of the catheter and proper drainage.

Choice B reason: Increasing the flow of the bladder irrigation is the best initial action. By increasing the flow, the nurse can help flush out the blood clots from the drainage tubing and ensure that the catheter remains patent. This action directly addresses the problem of blocked drainage and prevents further complications.

Choice C reason: Measuring the client's intake and output is important for overall monitoring, but it does not directly address the immediate concern of blood clots in the drainage tubing. Ensuring proper drainage is crucial to prevent complications such as bladder distention and further bleeding.

Choice D reason: Providing additional oral fluid intake is beneficial for maintaining hydration and promoting urine output, but it does not solve the problem of blood clots in the drainage tubing. The primary focus should be on ensuring the catheter's patency through irrigation.

A. Hypotension and venous pooling in the extremities B. Reports of chest pain and shortness of breath C. Pain and a burning sensation upon urination and hematuria D. Profuse diaphoresis and severe, pounding headache

Correct Answer is D

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are typically signs of neurogenic shock, which occurs immediately after a spinal cord injury. However, autonomic dysreflexia is characterized by severe hypertension, not hypotension. The symptoms in this scenario do not fit the presentation of autonomic dysreflexia.

Choice B reason: Reports of chest pain and shortness of breath are not the primary symptoms of autonomic dysreflexia. While autonomic dysreflexia can cause a variety of symptoms due to uncontrolled sympathetic nervous system activity, the hallmark symptoms are severe hypertension and headache, along with other specific signs like diaphoresis.

Choice C reason: Pain and a burning sensation upon urination and hematuria indicate a urinary tract infection or another urological issue, not autonomic dysreflexia. While a full bladder is a common trigger for autonomic dysreflexia, the symptoms described in this choice do not accurately reflect the condition.

Choice D reason: Profuse diaphoresis and a severe, pounding headache are classic symptoms of autonomic dysreflexia. This condition results from an overactive autonomic nervous system response to stimuli below the level of the injury, such as a full bladder. The resulting vasoconstriction leads to severe hypertension and symptoms like headache and sweating above the level of injury.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which is the best initial nursing action?

Correct Answer is B

Explanation

A client who had a C5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is D

Explanation

The nurse has conducted a cancer prevention community education program. In evaluating the participants' understanding of the carcinogens, which statement indicates an accurate understanding?

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The nurse is assessing a client who is one day postoperative parathyroidectomy and finds that the client is experiencing stridor. After notifying the healthcare provider (HCP), the nurse should prepare for which procedure?

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