The nurse is completing an assessment of a 6-year-old client with an asthma exacerbation. Which of the following assessment findings is of most concern to the nurse?
The nurse is completing an assessment of a 6-year-old client with an asthma exacerbation. Which of the following assessment findings is of most concern to the nurse?
A. Expiratory wheezing
[14%]
B. Sudden absence of wheezing
[72%]
C. Persistent cough
[1%]
D. Head bobbing
[13%]
Statistics
Subject/Lesson
Subject
Child Health
Lesson
Respiratory
Client Need
Test Plan
Physiological Adaptation
Related Topic
Alterations in Body Systems
Item Type
Item Type
Analysis
Explanation
Choice B is correct. Wheezing is expected during an exacerbation. If a client should experience a sudden absence of wheezing, this may indicate respiratory arrest. If the asthma attack improves, a gradual decrease in wheezing is expected (not a sudden cessation).
Choice A is incorrect. Expiratory wheezing is an expected finding when a client is having an asthma exacerbation. This occurs when there is inflammation in the airways and air trapping, making it hard for the client to exhale all the air in their lungs fully. The wheezing is audible as they attempt to exhale. Although it is a significant finding, it is not the finding of most concern in this question because the client still has a patent airway.
Choice C is incorrect. A persistent cough is an expected finding during an asthma exacerbation and is not of great concern.
Choice D is incorrect. Head bobbing is an indication of increased work of breathing in the pediatric client experiencing an asthma exacerbation. It occurs when the child's head moves forward each time they take a breath. This finding is significant and an indication that further support is needed, but it is not the priority.
Related Videos
2 Key Topics
Asthma
17.6 Airway Disorders
Additional Info
✓ Management of an asthma exacerbation involves prompt administration of oxygen and albuterol via nebulizer.
✓ Other medications indicated during an asthma exacerbation include prednisone and magnesium sulfate (which causes bronchodilation).
✓ The nurse should monitor the client for deterioration, including the sudden cessation of wheezing, decreasing oxygen saturation, and cardiac dysrhythmias.
