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 C
Explanation
C. Cushing's syndrome often leads to central (truncal) obesity, characterized by fat accumulation around the abdomen and face, while the extremities may appear relatively thin due to muscle wasting. This distribution of fat and muscle wasting contributes to the characteristic "moon face" appearance seen in individuals with Cushing's syndrome.
A. Visible swelling of the neck with no pain is not typically associated with Cushing's syndrome. Swelling of the neck may be indicative of other conditions such as goiter or thyroid nodules.
B. Warm, soft, moist, salmon-colored skin is not typically associated with Cushing's syndrome. Instead, individuals with Cushing's syndrome may exhibit thin, fragile, and easily bruised skin due to the effects of cortisol on collagen synthesis and skin integrity.
D. Husky voice and hoarseness are not typically associated with Cushing's syndrome. These symptoms may be indicative of vocal cord dysfunction or other conditions affecting the larynx or vocal cords.
Correct Answer is D
Explanation
D. Applying pressure to the site helps to reduce engorgement and promote normal blood flow. This action can help alleviate the localized congestion and ensure a more accurate fingerstick glucose measurement. Once the pressure is applied and the congestion subsides, the nurse can proceed with collecting the blood sample.
A. While selecting another finger may be considered if the initial fingerstick attempt was unsuccessful or if the fingertip is excessively traumatized, it may not be necessary if the observation of redness and engorgement can be addressed with appropriate pressure application to the site.
B. Assessing radial pulse volume is not directly relevant to addressing the observed redness and engorgement of the fingertip after milking. This action is more appropriate for evaluating peripheral circulation and arterial perfusion in other clinical contexts
C. Collecting the blood sample without addressing the observed redness and engorgement of the fingertip may result in a suboptimal sample quality and could cause discomfort or further tissue trauma to the client.
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