Medical Surgical Asthma #4

Question

During the nursing care of a client with asthma, the client experiences an acute asthma attack. As the nurse provides immediate interventions, which observation by the nurse is most concerning?

Answers

  1. Decreased wheezing and a silent chest.
    • Rationale:

      This answer is correct because when breath sounds become inaudible, air movement is restricted. Lack of air movement can cause the respiratory system to be unable to oxygenate the body. For this reason, decreased wheezing and a silent chest is concerning during an acute asthma attack, as it indicates asphyxia is possible.

  2. The use of accessory muscles to breathe.
    • Rationale:

      This answer is not correct because although use of accessory muscle is concerning, it is expected during an acute asthma attack. When a client is trying hard to breathe, extra muscles assist and cause retractions.

  3. Coarse breath sounds and wheezing.
    • Rationale:

      This answer is not correct because during an acute asthma attack, the client will have coarse loud breath sounds and experience audible wheezing. A rescue inhaler can provide quick relief of symptoms.

  4. Restlessness and diaphoresis.
    • Rationale:

      This answer is not correct since a client is expected to become restless and sweaty while laboring to breathe. This can also be from the anxiety the client experiences as a result of not being able to breath properly.

Overview

During an acute asthma attack, the client will become restless and experience chest tightness, a nonproductive or productive cough, retractions, loud breath sounds, wheezing, and diaphoresis. When the breath sounds become inaudible, and wheezing decreases, there is lack of air movement and asphyxia can occur.

Explanation

Learning Outcomes

During an acute asthma attack, the client will become restless and experience chest tightness, a nonproductive or productive cough, retractions, loud breath sounds, wheezing, and diaphoresis. Coarse, loud breath sounds will be heard as the client tries to move air in and out. Sometimes the client will experience intercostal retractions. Retractions occur as a result of the muscles assisting in the respiratory effort. As the client labors to breathe, they will become restless and diaphoretic. When the breath sounds become inaudible, and wheezing decreases, there is lack of air movement. It is when this happens, the client is at risk for asphyxia.

Test Taking Tip

Know the signs and symptoms of an acute asthma attack and when to initiate respiratory support.

Video Rationale