An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with:
a. Asthma.
b. Atelectasis.
c. Lobar pneumonia.
d. Heart failure.
ANS: A
Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma.
You might also like to view...
When providing safety during nursing procedures, the nurse always begins with the following basic interventions. Place them in the correct sequence. Standard Text: Click and drag the options below to move them up or down. Choice
1. Choice 2. Choice 3. Check the physician's order Choice 4. Provide privacy as needed Choice 5. Explain the procedure Choice 6. Gather the necessary equipment
The nurse is very observant of patient behavior because all behavior has meaning and is:
a. preformed. b. important. c. learned. d. repeated.
The nurse is assessing a client who had a dissection of all branches of the right trigeminal nerve. When asked to wrinkle his forehead, the client wrinkles only the left side. Which is the nurse's best action?
a. Place the client in high Fowler's position. b. Document the finding. c. Assess the corneal reflex. d. Notify the health care provider.
Malignant cell growth is uncontrolled because of which action?
a. Cancer cells always divide more rapidly than normal cells. b. Mitosis of malignant cells usually pro-duces more than two daughter cells. c. Malignant cells bypass one or more phases of the cell cycle during cell division. d. Malignant cells enter the cell cycle fre-quently, making cell division continuous.