The nurse reviews the client history of the presenting illness in the electronic medical record.
Click to highlight the two pieces of key subjective data which indicate the client is in need of health interventions.
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue inhaler three times, but he just couldn't catch his breath.
The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The client reports using a rescue inhaler three times, but he just couldn't catch his breath
symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous
inhaler was expired and was worried the medication was not working
able to answer questions, pausing every few words to catch his breath
The client reports that it has been a couple of months since he had an asthma attack
The Correct Answer is ["A","B"]
In the provided scenario, the two key pieces of subjective data indicating the need for health interventions are the client's report of using a rescue inhaler multiple times without relief and the exacerbation of symptoms when outdoors and during exercise. These details suggest that the client's asthma is not well-controlled, and the ineffectiveness of the rescue medication, especially with an expired inhaler, warrants immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Teaching the importance of medication regimen and follow-up protocol is crucial for treating gonorrhea and preventing its spread to others. It addresses the immediate health concern and helps prevent further transmission.
B. While partners without symptoms may not show signs of infection, they could still be carriers of gonorrhea and should be tested and treated if necessary.
C. While using safe sex practices can reduce the risk of STIs, it may not completely eliminate the risk, especially if a partner has multiple sexual partners.
D. While sexual intercourse is a common mode of transmission for STIs, not all STIs are transmitted exclusively through sexual intercourse.
Correct Answer is ["A","B","C","D","F"]
Explanation
A. The patient’s oxygen saturation remains below the target of 94% despite initial oxygen therapy. Therefore, increasing the oxygen flow might be necessary to achieve better oxygenation.
B. Since the patient remains symptomatic with ongoing wheezes, administering another dose of the nebulizer treatment as ordered, since the prescription included PRN can help to further open the airways and alleviate wheezing.
C. Elevating the head of the bed can help improve lung expansion and ease the work of breathing, which is particularly beneficial in respiratory distress situations.
D. Switching to a nonrebreather mask may be appropriate if the patient’s oxygen saturation does not improve sufficiently with the current method of oxygen delivery. This type of mask can deliver a higher concentration of oxygen.
E. While incentive spirometry is generally used for preventing pulmonary complications (such as pneumonia or atelectasis) after surgery or in conditions where patients are likely to be immobile, it may not be immediately beneficial or a priority in the acute management of an asthma attack. The primary focus should be on stabilizing the patient’s respiratory status through medication and oxygen therapy. Thus, this option is less critical at this stage.
F. Continuous monitoring of vital signs is crucial in acute cases like this to assess the patient's response to interventions and detect any deterioration in the clinical status.
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