Patient Data

Exhibits

The nurse has implemented additional needed actions.

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one, but may have more than one answer selected.

Assessment Data: Indicates the Interventions Were Successful/ No Indication that the Interventions Were Successful

Heart Rate 105 beats/minute

Client can now speak in full sentences without pausing.

Lung sounds clear

Respirations 16 breaths/minute

Client reports, “It’s a lot easier to breathe now.”

Blood Pressure 122/84 mmHg

Answer and Explanation

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

Correct Answers:

Indicates the Interventions Were Successful: A, B, C, D, E, F

No Indication that the Interventions Were Successful: None

Rationale:

The assessment data provided indicates a positive response to the interventions for the asthma attack. The decrease in heart rate from 112 to 105 beats per minute, alongside the client's ability to speak in full sentences without pausing, suggests an improvement in respiratory function. Clear lung sounds and a reduction in respiratory rate to 16 breaths per minute further support this conclusion. The client's subjective report of eased breathing and the maintenance of blood pressure within normal limits post-intervention are also indicative of successful treatment. These observations collectively demonstrate the effectiveness of the administered medications and oxygen therapy in managing the acute asthma symptoms presented by the client.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Husky voice and hoarseness are not typically associated with Cushing's syndrome but may be related to other conditions affecting the throat or vocal cords.

B. Central type obesity, with thin extremities, is a classic manifestation of Cushing's syndrome due to excess cortisol, which promotes fat accumulation in the trunk and face while causing muscle wasting in the extremities.

C. Warm, soft, moist, salmon-colored skin is not typically associated with Cushing's syndrome and may indicate other dermatological conditions.

D. Visible swelling of the neck with no pain is not a characteristic finding of Cushing's syndrome and may indicate other underlying issues such as goiter or lymphadenopathy.

A. Hemoglobin levels. B. White blood cell count. C. Red blood cell count. D. Platelet count.

Correct Answer is D

Explanation

A. Hemoglobin levels primarily indicate the oxygen-carrying capacity of the blood and are not typically affected in conditions associated with petechiae and ecchymosis.

B. White blood cell count may be elevated in response to infection but is not directly related to the presence of petechiae and ecchymosis.

C. Red blood cell count primarily reflects the oxygen-carrying capacity of the blood and is not typically affected in conditions associated with petechiae and ecchymosis.

D. Platelet count is crucial in assessing for thrombocytopenia, a condition characterized by low platelet levels, which can lead to increased bleeding and bruising, including petechiae and ecchymosis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

Correct Answer is B

Explanation

The nurse assesses a client with petechiae and ecchymosis scattered across the arms and legs. Which laboratory result should the nurse review?

Correct Answer is D

Explanation

A client who works as a data entry clerk is concerned as to how a recent diagnosis of Raynaud's syndrome is going to affect the client's job performance. Which instruction should the nurse provide this client?

After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?

A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?

The nurse is caring for a client who is receiving teletherapy radiation for a malignant tumor. Which instruction regarding skin care of the portal site should the nurse provide?

Patient Data Exhibits After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.

While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.