Question Of The Day: The Nursing Process

Q. The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect which of the following?

A. Increased forced expiratory volume.
B. Normal breath sounds.
C. Inspiratory and expiratory wheezing.
D. Morning headaches.



Correct Answer: C

Reason: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations, there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume [forced expiratory flow (FEF) is the flow (or speed) of air coming out of the lung during the middle portion of a forced expiration] due to bronchial constriction. Morning headaches are found with more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.