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":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}

Explanation

Rationale:

Report of pain: Abdominal pain is common in both cirrhosis and viral hepatitis due to liver inflammation, capsule stretching, or complications like ascites. In hepatitis, pain is often acute and located in the right upper quadrant, while in cirrhosis, it may be more generalized or related to portal hypertension.
Eye sclera finding: Jaundice, noted as yellowing of the sclera, occurs in both conditions due to impaired bilirubin metabolism. In cirrhosis, it's due to chronic hepatocellular failure, while in viral hepatitis, it's from acute inflammation impairing bilirubin excretion.
Alcohol intake history: A 25-year history of heavy alcohol use is a strong risk factor for alcoholic cirrhosis. While alcohol use can worsen viral hepatitis, it is not a primary cause of viral hepatitis, which is due to infection with hepatitis viruses (A, B, C, etc.).
Report of energy level: Fatigue is a common symptom in both conditions due to impaired liver function, toxin accumulation, anemia, or systemic inflammation. In viral hepatitis, fatigue is often sudden and profound, while in cirrhosis, it is usually chronic and progressive.

A. Oral temperature of 37.2° C (99° F) B. Clear drainage on the dressings C. Drain output 75 mL in 4 hr D. Decreased bowel sounds in all quadrants of the abdomen

Correct Answer is B

Explanation

Rationale:
A. Oral temperature of 37.2° C (99° F): This is a normal postoperative temperature and does not indicate infection or any other complication. Mild elevations in temperature are expected after surgery.

B. Clear drainage on the dressings: Clear drainage, particularly if it is watery and not tinged with blood, may indicate cerebrospinal fluid (CSF) leakage. This is a serious complication of spinal surgery and requires immediate evaluation to prevent infection and further neurological issues.

C. Drain output 75 mL in 4 hr: This amount of drainage is within normal limits for the early postoperative period, depending on the surgeon's parameters. It is not inherently concerning unless it becomes excessive or has abnormal characteristics.

D. Decreased bowel sounds in all quadrants of the abdomen: Decreased bowel activity is common after surgery due to anesthesia and immobility. It is expected in the immediate postoperative period and not necessarily a sign of a complication unless prolonged.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

For each client assessment finding below, click to specify if the finding is consistent with cirrhosis or viral hepatitis: Each finding may support more than one disease process Exhibits

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"A,B"}}

Explanation

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Correct Answer is B

Explanation

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