The nurse reviews the client 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.

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

symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous

inhaler was expired and was worried the medication was not working

able to answer questions, pausing every few words to catch his breath

The client reports that it has been a couple of months since he had an asthma attack

Answer and Explanation

The Correct Answer is ["A","B"]

In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Bronze pigmentation is not typically associated with compromised peripheral arterial circulation but may be seen in conditions like hemochromatosis.

B. Lower leg edema is more commonly associated with venous insufficiency rather than compromised arterial circulation.

C. Uneven hair distribution, such as decreased hair growth on the lower extremity, is indicative of compromised peripheral arterial circulation due to reduced blood flow to the area.

D. Bounding peripheral pulse is not typically associated with compromised peripheral arterial circulation but may indicate increased stroke volume or arterial stiffness.

A. Hemoglobin levels. B. White blood cell count. C. Red blood cell count. D. Platelet count.

Correct Answer is D

Explanation

A. Hemoglobin levels primarily indicate the oxygen-carrying capacity of the blood and are not typically affected in conditions associated with petechiae and ecchymosis.

B. White blood cell count may be elevated in response to infection but is not directly related to the presence of petechiae and ecchymosis.

C. Red blood cell count primarily reflects the oxygen-carrying capacity of the blood and is not typically affected in conditions associated with petechiae and ecchymosis.

D. Platelet count is crucial in assessing for thrombocytopenia, a condition characterized by low platelet levels, which can lead to increased bleeding and bruising, including petechiae and ecchymosis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing a physical assessment of a client. Which finding should the nurse recognize is a result of a compromised peripheral arterial circulation of the lower extremity?

Correct Answer is C

Explanation

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

Correct Answer is D

Explanation

The nurse is caring for a client who tests positive for the sexually transmitted infection (STI) gonorrhea. The client reports having sex with someone who has many partners. Which response should the nurse provide?

Patient Data. Exhibits Complete the following sentences by choosing from the lists of corresponding options. Based on history and assessment data, the nurse should prioritize dropdown as the priority problem for this client, as evidenced by the client's statement, dropdown.

The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. Which action should the nurse take?

When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

The nurse is assessing a client who has herpes zoster. Which question will allow the nurse to gather further information about this condition?

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?