Patient Data

History and Physical

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

Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.

The client reports using a rescue inhaler three times, but he just couldn't catch his breath

The client reports that symptoms seem worse when outdoors and when exercising

episodes like this make him extremely nervous

it has been a couple of months since he had an asthma attack

noticed that his inhaler was expired and was worried the medication was not working

Answer and Explanation

The Correct Answer is ["A"]

Subjective data refers to the symptoms reported by the client while objective data refers to the information collected on assessment of the client. During asthmatic attack, the client reports of shortness of breath, audible wheezing, inability to speak in complete sentences and a feeling of nervousness.

The use of a reliever without relief during an asthmatic attack indicates the severity of the attack. This requires intervention including the introduction of inhaled corticosteroids to reduce airway inflammation and remodeling.

The recurrence of symptoms on exposure to exercise requires the need for further advise to avoid triggers and recurrence of symptoms.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

D Initiating IV access with two large bore catheters allows for rapid administration of medications and fluids as needed. Additionally, reviewing the inclusion criteria for IV fibrinolytic therapy is crucial to determine if the client is eligible for this time-sensitive intervention.
Fibrinolytic therapy aims to dissolve blood clots and restore blood flow to the brain, potentially reducing the extent of neurological deficits and improving outcomes in ischemic stroke.
A While laboratory tests such as prothrombin time and platelet count may be important for assessing coagulation status and ruling out bleeding disorders, they are not the priority in the immediate management of a suspected stroke
B Aspirin is commonly used for secondary prevention of ischemic stroke, but its administration in the acute phase of a suspected stroke depends on the specific clinical scenario and treatment guidelines. Aspirin may be contraindicated if IV fibrinolytic therapy is being considered or if the type of stroke is hemorrhagic.
C Elevating the affected limb may be beneficial in certain neurological conditions to reduce swelling or edema, but it is not the priority intervention in the immediate management of a suspected stroke.

A. Ensure a large gauge IV catheter is used to obtain blood samples. B. Monitor urine and stool for occult blood regularly. C. Remove cold and frozen foods from dietary trays. D. Wrap bruised areas with elastic bandage dressings.

Correct Answer is B

Explanation

B. Thrombocytopenia, or low platelet count, increases the risk of spontaneous bleeding, which can manifest as occult blood in the urine or stool. Regular monitoring allows for early detection of bleeding complications, prompting timely intervention and preventing further complications.
A. While using a large gauge IV catheter may be appropriate to minimize trauma and bleeding risk during blood sampling in a client with thrombocytopenia, it is not the highest priority intervention.
C. Removing cold and frozen foods from dietary trays may be advised in clients with thrombocytopenia to minimize the risk of cold-induced platelet aggregation and potential vascular occlusion, known as cold agglutinin disease. However, this intervention is not directly related to preventing bleeding complications associated with thrombocytopenia.
D. Wrapping bruised areas with elastic bandage dressings may provide support and protection but is not the most appropriate intervention for managing thrombocytopenia-related bleeding complications.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?

The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, "Penicillin 500,000 units/mL". How many mL should the nurse administer to this client? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

Patient Data Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client's history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.