A patient is admitted with asthma. The nurse's assessment finds a temperature of 99 ° F, wheezing, speaking in three-word phrases, and respiratory rate of 16 breaths per minute
Which of the following are the best defining characteristics to support the diagnosis of ineffective airway clearance related to inflammation and constriction of the bronchial tree?
a.
Elevated temperature and respiratory rate
b.
Diagnosis of asthma with wheezing
c.
Wheezing and speaking in three-word phrases
d.
Limited vocalization and fever
ANS: C
A
Neither the temperature nor the respiratory rate is outside of the norms of an adult.
B
The medical diagnosis is not a defining characteristic.
C
The constriction causes wheezing and difficulty vocalizing.
D
There is no fever.
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