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Patient Data

History and Physical

The client is a 22-year-old female with a history of asthma. She was diagnosed at the age of 4 years old and has had 2 previous hospitalizations for asthma-related symptoms at ages 14 and 16. She denies smoking but drinks alcohol 1 to 2 times a week. She reports taking edible marijuana to relieve severe premenstrual symptoms. She came to the emergency department when she started having difficulty breathing on a hike. She took her usual dose of albuterol, but the symptoms did not resolve. The client’s friend called an ambulance when they noticed her distress.

Nurses’ Notes

The client is admitted to the medical floor. She has mild subcostal retractions and is sitting in an upright position. Wheezes are noted throughout the lung fields. The client is pale. She has strong peripheral pulses that are equal bilaterally.

Vital Signs

Her heart rate is 122 beats/minute, blood pressure 134/85 mm Hg, oxygen saturation 91% on room air.

Click to highlight the assessment findings that require immediate follow up by the nurse.

diagnosed at the age of 4 years old and has had 2 previous hospitalizations

reports taking edible marijuana

started having difficulty breathing on a hike

took her usual dose of albuterol, but the symptoms did not resolve

mild subcostal retractions

Wheezes are noted throughout the lung fields

client is pale

heart rate is 122 beats/minute

blood pressure 134/85 mm Hg

oxygen saturation 91% on room air

Answer and Explanation

The Correct Answer is ["C","D","E","F","G","H","J"]

Based on the provided information, the following assessment findings require immediate follow-up by the nurse:

Difficulty breathing on a hike: This is a significant symptom of asthma exacerbation and needs immediate attention.
Symptoms did not resolve after taking albuterol: Albuterol is a quick-relief medication for asthma symptoms. If symptoms do not improve after its use, it indicates that the asthma exacerbation is severe.
Mild subcostal retractions: This is a sign of respiratory distress and indicates that the client is using accessory muscles to breathe.
Wheezes noted throughout the lung fields: Wheezing is a common sign of asthma and indicates airway obstruction.
The client is pale: Paleness can be a sign of decreased oxygenation.
Heart rate of 122 beats/minute: A high heart rate can be a sign of distress or could be due to the body’s attempt to compensate for decreased oxygenation.
Oxygen saturation of 91% on room air: Normal oxygen saturation is typically 95% or higher. A saturation of 91% indicates that the client is not getting enough oxygen.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Choice A rationale

Administering morphine as prescribed would help to manage the patient’s reported pain.

Choice B rationale

Monitoring the patient’s vital signs is crucial in assessing the patient’s physiological response to the fall and ensuring stability.

Choice C rationale

Applying a cold pack to the affected area can help to reduce swelling and alleviate pain.

Choice D rationale

Arranging for an X-ray of the left shoulder would help to identify any potential fractures or other injuries resulting from the fall.

A. Decreased range of motion B. Pain with movement C. Reduced strength in left upper extremity D. Reduced pulse distal to injury E. Coolness of the skin

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

Explanation

Choice A rationale

Decreased range of motion is generally associated with a rotator cuff injury. This is because the rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of the upper arm bone firmly within the shallow socket of the shoulder. When these muscles or tendons are injured, it can limit the shoulder’s range of motion.

Choice B rationale

Pain with movement can be a symptom of both a rotator cuff injury and a humeral fracture. Both conditions involve structures that are integral to the movement of the arm, and damage to these structures can cause pain when they are moved or put under strain.

Choice C rationale

Reduced strength in the left upper extremity is more commonly associated with a rotator cuff injury. The rotator cuff is responsible for the stability of the shoulder joint and enables the arm to lift and rotate. An injury to the rotator cuff can therefore lead to a reduction in the strength of the arm.

Choice D rationale

Reduced pulse distal to the injury is more commonly associated with a humeral fracture. This is because a fracture to the humerus could potentially damage the blood vessels running along the bone, leading to a reduced pulse further down the arm.

Choice E rationale

Coolness of the skin is more commonly associated with a humeral fracture. This could be due to damage to the blood vessels, leading to reduced blood flow and therefore a lower skin temperature.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

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

Explanation

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