A parent brings their child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Frequency that the child uses a rescue inhaler during the week.

Type of inhaler the child typically uses on a regular basis.

Type of allergen exposure or trigger for the current episode.

Last dose and type of rescue inhaler used by the child.

Answer and Explanation

The Correct Answer is D

A. Frequency that the child uses a rescue inhaler during the week: While it is important to know how often the child uses a rescue inhaler, it does not provide immediate, critical information to assess the severity of the current asthma attack.

B. Type of inhaler the child typically uses on a regular basis: While knowing the type of inhaler the child uses regularly can provide insight into their asthma management, it is not the most critical information at this moment, the current treatment is he most urgent.

C. Type of allergen exposure or trigger for the current episode: Understanding the trigger for the current asthma episode is helpful for long-term management but is not as urgent in the immediate assessment of the child’s condition during an acute exacerbation.

D. Last dose and type of rescue inhaler used by the child: This information helps assess whether the child has received appropriate treatment and whether additional or different interventions are needed immediately to address the asthma exacerbation, helps guide further treatment decisions.

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Correct Answer is D

Explanation

A. Only when a client presents with an unexplained injury: Waiting for physical signs misses many victims, especially those experiencing emotional or sexual abuse without visible injuries.

B. As soon as the clinician suspects a problem: While suspicion should prompt further evaluation, relying on suspicion alone delays early detection and intervention for many at-risk individuals.

C. Once the clinician confirms a history of abuse: Screening is a preventive tool used to detect abuse early; waiting for confirmation defeats the purpose and allows ongoing harm.

D. As a routine part of each health care encounter: Routine screening normalizes the process, reduces stigma, and increases the likelihood of identifying and helping those experiencing IPV.

A. Demonstrate to the PN how to position the client more effectively for the procedure. B. Arrange for unlicensed assistive personnel to assist the PN during the procedure. C. Acknowledge that the PN has positioned the client safely and correctly. D. Assume care of the client and assign the PN to the care of a different client.

Correct Answer is A

Explanation

A. Demonstrate to the PN how to position the client more effectively for the procedure:
The correct position for a sigmoidoscopy is the left lateral or Sims' position to allow easier access to the sigmoid colon. Demonstrating the correct position supports patient safety and provides teaching for the PN.

B. Arrange for unlicensed assistive personnel to assist the PN during the procedure: Assistance is not the issue in this scenario; the problem lies in incorrect positioning. Assigning additional help does not address the need to correct the client's position.

C. Acknowledge that the PN has positioned the client safely and correctly: The flat prone position is not appropriate for a sigmoidoscopy. Acknowledging incorrect positioning would be unsafe and potentially delay the procedure or increase the risk of injury.

D. Assume care of the client and assign the PN to the care of a different client: This is an excessive response that undermines the PN’s role. The more constructive approach is to guide and support the PN through demonstration rather than reassignment.

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A parent brings their child, who has a history of asthma, to the emergency room. The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When should intimate partner violence (IPV) screening occur?

Correct Answer is D

Explanation

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Correct Answer is A

Explanation

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