A client is being treated for an acute exacerbation of asthma. Which assessment finding indicates to the nurse that the goals of treatment are being met?

The nurse observes the client using accessory muscles while breathing.

The client is able to answer questions in full sentences.

Lung auscultation demonstrates diminished breath sounds.

The client appears restless and anxious when resting in bed.

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Using accessory muscles while breathing is a sign of respiratory distress and indicates that the client is working harder to breathe. This is not a desired outcome of treatment and suggests that the asthma exacerbation is not under control.

Choice B Reason:

The ability to answer questions in full sentences suggests that the client's airway is not severely obstructed, which is a positive sign of effective asthma treatment. When asthma is well-controlled, individuals should not experience significant shortness of breath that limits their ability to speak.

Choice C Reason:

Diminished breath sounds can be a sign of severe airway obstruction and are not indicative of effective asthma treatment. Ideally, lung auscultation should reveal clear breath sounds without wheezing, indicating good air movement throughout the lungs.

Choice D Reason:

Restlessness and anxiety can be symptoms of hypoxia, a condition where the body or a region of the body is deprived of adequate oxygen supply. This is not a sign of effective asthma treatment and may indicate that the client's asthma is not well-managed.

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Correct Answer is D

Explanation

Choice A Reason
A client with paranoid personality disorder is typically not described as superficially charming. This description is more often associated with other personality disorders, such as antisocial personality disorder, where individuals may use charm to manipulate others for personal gain.

Choice B Reason
Being friendly and open is generally not characteristic of paranoid personality disorder. Individuals with this disorder are often wary of others and may be perceived as cold or distant due to their mistrust.

Choice C Reason
While intensity and impulsivity can be seen in various personality disorders, they are not the defining features of paranoid personality disorder. These traits are more commonly associated with borderline personality disorder.

Choice D Reason
Guarded and suspicious are hallmark descriptors for someone with paranoid personality disorder. Individuals with this condition are often very distrustful of others, suspecting that others have ulterior motives or are out to harm them. They may be preoccupied with doubts about the loyalty or trustworthiness of friends or associates.

A. Run the bag under warm water to melt the globules. B. Call the pharmacy to get a new bag of TPN. C. Do nothing, as fat globules are expected to rise to the top of the TPN solution. D. Roll the bag of solution gently to redistribute the fat.

Correct Answer is B

Explanation

Choice A Reason
Running the bag under warm water to melt the globules is not recommended. Applying heat could compromise the sterility and integrity of the solution. TPN solutions are carefully balanced and sterile, and any manipulation involving temperature changes could lead to contamination or nutrient degradation.

Choice B Reason
Observing fat globules at the top of the TPN solution is a sign that the emulsion may be compromised. The nurse should not administer this TPN solution and should call the pharmacy for a replacement. TPN solutions should be homogenous with no visible separation or fat globules to ensure the patient receives the correct nutrition and to prevent complications.

Choice C Reason
Doing nothing is not an appropriate action. Fat globules indicate that the solution has separated, which can lead to an unstable emulsion and potential harm if infused. The nurse's responsibility is to ensure the safety and efficacy of the treatment, which includes verifying that TPN solutions are properly mixed.

Choice D Reason
Rolling the bag gently to redistribute the fat is not a safe practice. While gentle agitation can be used for some medications, it is not appropriate for TPN solutions with visible fat globules. This could further destabilize the emulsion and does not address the underlying issue of separation.

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A client is being treated for an acute exacerbation of asthma. Which assessment finding indicates to the nurse that the goals of treatment are being met?

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Naxlex Comprehensive Predictor Exams

The edited text with the question and the choices labeled from a to d is as follows: The nurse who assesses a client as having paranoid personality disorder is most likely to describe the client as:

Correct Answer is D

Explanation

The nurse is preparing to hang the client's next bag of Total Parenteral Nutrition (TPN) and observes fat globules rising to the top of the solution. What action should the nurse take?

Correct Answer is B

Explanation

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