An adult client has been admitted to the hospital with asthma exacerbation. Which trigger should the nurse identify as being the most significant cause of this client's asthma complications?

The client gained 5 pounds (2.27 kg) over the last six months.

A family member recently contracted viral influenza.

There is a known family history of lung disease.

The client cleaned house with cleaning supplies.

Answer and Explanation

The Correct Answer is D

Choice A reason: Gaining weight over six months can affect overall health and potentially exacerbate asthma symptoms by increasing the workload on the respiratory system. However, it is not an immediate trigger for asthma exacerbation.

Choice B reason: A family member contracting viral influenza poses a risk of the client catching the virus, which can exacerbate asthma. However, it is not a direct trigger of the asthma exacerbation unless the client actually contracts the virus.

Choice C reason: A family history of lung disease can indicate a genetic predisposition to respiratory issues, but it is not an immediate trigger for an asthma exacerbation.

Choice D reason: Cleaning with household supplies is a significant trigger for asthma exacerbation. Many cleaning products contain strong chemicals that can irritate the airways and provoke an asthma attack. This is the most immediate and direct cause of the client's asthma complications among the given options.

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Correct Answer is C

Explanation

Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.

Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.

Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.

Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.

A. Reduce the client's interaction with others during the day. B. Awaken the client for reality checks every 4 hours at night. C. Clarify reality with the client about delusional thoughts. D. Use distraction and therapeutic communication skills.

Correct Answer is D

Explanation

Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.

Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.

Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.

Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.

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An adult client has been admitted to the hospital with asthma exacerbation. Which trigger should the nurse identify as being the most significant cause of this client's asthma complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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