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 B
Explanation
B. Dietary intake plays a significant role in the management of chronic pancreatitis pain. Certain foods, especially those high in fat, can exacerbate symptoms and trigger pain episodes in clients with pancreatitis.
A. While assessing the activity level of bowel sounds is important for monitoring gastrointestinal function, it is not the most crucial assessment data in this scenario. Bowel sounds may be decreased or absent in clients with severe abdominal pain, but addressing the dietary triggers of chronic pancreatitis pain takes priority.
C. Assessing the level and amount of physical activity is important for overall health and may play a role in managing chronic pancreatitis. However, in the context of persistent gnawing abdominal pain, addressing dietary factors that exacerbate the pain is more immediate and crucial.
D. Assessing the color and consistency of feces is important for monitoring gastrointestinal function and identifying signs of malabsorption or steatorrhea, which can occur in chronic pancreatitis. However, in the context of persistent gnawing abdominal pain, assessing dietary intake and potential triggers of pain is more pertinent to pain management.
Correct Answer is B
Explanation
B. Hematuria can indicate renal involvement, which is a serious complication of SLE. Lupus nephritis, inflammation of the kidneys caused by SLE, can lead to hematuria, proteinuria, and impaired kidney function. Monitoring for renal complications is essential in managing SLE exacerbations, and hematuria warrants immediate attention to assess the extent of renal involvement and adjust treatment as necessary.
A. Joint pain is a common symptom of systemic lupus erythematosus (SLE), an autoimmune disease that can affect multiple organs and tissues, including the joints. While joint pain can be distressing for the patient, it is not necessarily an urgent or life-threatening complication requiring immediate intervention.
C. Muscle atrophy, or the wasting away of muscle tissue, can occur in individuals with systemic lupus erythematosus (SLE), particularly if they are experiencing prolonged periods of inactivity due to joint pain, fatigue, or other symptoms. While muscle atrophy can contribute to functional impairment and decreased quality of life, it is not typically considered an urgent or life-threatening complication requiring immediate intervention.
D. Low-grade fever is a common symptom in systemic lupus erythematosus (SLE), often occurring during disease flares or exacerbations. Monitoring the patient's temperature and assessing for other signs of infection or disease activity is important, but low-grade fever alone may not warrant urgent intervention.

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