An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?

Coughing

Flat neck veins

Use of accessory muscles

Presence of coarse crackles

Answer and Explanation

The Correct Answer is C

Rationale:
A. Coughing: While coughing is a common symptom of asthma, it is not specific to status asthmaticus. It can occur during mild, moderate, or severe asthma episodes and does not necessarily indicate life-threatening severity.

B. Flat neck veins: Flat neck veins are not characteristic of status asthmaticus. In severe respiratory distress, the client may show signs of increased intrathoracic pressure, which can lead to distended neck veins rather than flat ones.

C. Use of accessory muscles: The use of accessory muscles to breathe is a sign of severe respiratory distress and indicates that the client is struggling to maintain adequate ventilation. This is a hallmark of status asthmaticus, a life-threatening condition requiring immediate intervention.

D. Presence of coarse crackles: Coarse crackles are more commonly associated with fluid in the lungs, such as in pneumonia or heart failure. In status asthmaticus, breath sounds may be diminished or absent due to severe airway obstruction, rather than producing crackles.

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Correct Answer is A

Explanation

Rationale:
A. Remove clutter from rooms and hallways: Keeping the environment free of clutter helps reduce confusion, prevents falls, and promotes safety for clients with Alzheimer’s disease, who often have impaired spatial awareness and judgment.

B. Place a monthly calendar in the client's room: A monthly calendar may be too complex and difficult for a client with Alzheimer's to interpret. Simpler tools, like a daily schedule or clock with the day and date, are more appropriate for supporting orientation.

C. Use confrontation to manage the client's behavior: Confrontation can increase agitation and confusion in clients with Alzheimer’s disease. A calm, supportive, and redirecting approach is more effective for managing difficult behaviors.

D. Review the daily schedule with the client every morning: While routine is beneficial, clients with moderate to severe Alzheimer’s may not retain or comprehend daily plans. Short, simple reminders throughout the day are often more effective than once-daily reviews.

A. N95 respirator B. Goggles C. Disposable gown D. Surgical mask

Correct Answer is D

Explanation

Rationale:
A. N95 respirator: N95 respirators are required for airborne precautions, such as with tuberculosis, measles, or varicella. Bacterial meningitis, caused by organisms like Neisseria meningitidis, requires droplet precautions, which do not necessitate an N95 mask.

B. Goggles: Goggles are used for protection against splashes or sprays of bodily fluids, particularly in procedures that may cause aerosolization. While helpful in certain situations, goggles are not required as part of standard droplet precautions for meningitis.

C. Disposable gown: Gowns are worn during contact precautions or when there is a risk of contamination from bodily fluids. They are not routinely required for droplet precautions unless the nurse anticipates contact with large amounts of secretions.

D. Surgical mask: A surgical mask is the appropriate PPE for droplet precautions, which are necessary for clients with bacterial meningitis. The mask prevents the spread of infectious respiratory droplets that can travel up to 3 feet during coughing or sneezing.

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An emergency room nurse is assessing a client who has asthma and difficulty breathing. Which of the following findings should indicate to the nurse that the client is experiencing status asthmaticus?

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