Patient Data
The nurse performs an initial focused assessment of the client.
Based on the client's history and assessment data, the nurse's hypothesis is that the client's vital signs are most likely the result of disease process, medication use, or neither. Each column must have at least one, but may have more than one answer selected.
Blood pressure 130/86 mmHg
Respirations 28 breaths/minute
Temperature 98.9" F (37.1°C)
Heart rate 112 beats/minute
Oxygen saturation 88% on room air
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"B"}}
In an asthmatic attack, exposure to triggers leads to bronchospasm which blocks airflow leading to impaired ventilation that manifests as respiratory distress- tachypnea. This prevents oxygenation with resultant hypoxia as evidenced by low SPO2 levels. Continuous use of a non- selective beta agonists leads to elevated heart rate.
Acute asthmatic attacks are not associated with changes in blood pressure
Acute asthmatic attacks are not associated with changes in temperature. However, when triggered by pulmonary infections, the client may experience episodes of fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. The client is noted to have emesis which contributes to total fluid loss predisposing the client to acute kidney injury. Antiemetics are important to reduce emesis.
B. Clients with PCP are typically treated with antibiotics, such as trimethoprim-sulfamethoxazole (TMP-SMX), as first-line therapy. Monitoring for adverse reactions to antibiotics, such as hypersensitivity reactions or renal toxicity, is essential for safe medication administration.
Increasing fluid intake prevents and manages acute kidney injury in the client.
C. Increasing intravenous hydration ensures the lost fluid is replaced to prevent acute renal injury that may occur due to hypoperfusion.
D. Pneumocystis pneumonia is caused by the fungus Pneumocystis jirovecii (formerly known as Pneumocystis carinii), and its transmission occurs through the inhalation of airborne fungal spores. However, it is not typically spread from person to person like airborne viral or bacterial infections.
E. Repeating CD4 count is not necessary as it is unlikely to alter the management of the client at this point. This should be after 2-3 weeks.
Correct Answer is A
Explanation
A. Compromised peripheral arterial circulation can lead to decreased blood flow to the extremities, resulting in poor tissue perfusion. Over time, this can cause changes in the skin and hair distribution. Uneven hair distribution, or sparse hair growth, is a characteristic finding in areas of reduced arterial circulation due to inadequate oxygen and nutrient delivery to the hair follicles.
B. Lower leg edema is more commonly associated with compromised venous circulation rather than arterial circulation. It occurs due to impaired venous return, leading to fluid accumulation in the tissues.
C. Bronze pigmentation of the skin is not typically associated with compromised peripheral arterial circulation. Bronze pigmentation can occur in conditions such as hemochromatosis or Addison's disease but is not a specific sign of peripheral arterial disease.
D. In peripheral arterial disease, peripheral pulses may be diminished or absent due to arterial narrowing or occlusion. Bounding peripheral pulses are more commonly associated with conditions such as arterial hypertension.
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