What will nurse do if she receives a patient with status asthmaticus manifest with tachypnea, laboured respiration with effort on exhalation, tachycardia, elevated blood pressure and is irritable?

1. A

   Administer treatment as prescribed

2. B

   Monitor i/v therapy and give bronchodilators

3. C

   Start oxygen & check vital signs

4. D

   Provide comfortable position and check vital signs

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2015

Explanation

• The patient's irritability is a key sign of altered mental status, indicating cerebral hypoxia (insufficient oxygen to the brain), which is a life-threatening emergency.
• The priority nursing action is determined by the ABCs (Airway, Breathing, Circulation). The primary problem here is compromised breathing leading to hypoxia.
• Starting supplemental oxygen is the most immediate and direct intervention to correct hypoxemia, prevent further neurological damage, and stabilize the patient.
• Checking vital signs is essential to establish a baseline and continuously monitor the patient's response to treatment and detect any signs of deterioration.

Why Other Options Were Wrong

• Option A: This option is too general and not specific enough for an emergency situation. The nurse must take a direct, life-saving action first.
• Option B: While bronchodilators are the definitive treatment to reverse bronchospasm, they are not the first priority when a patient is hypoxic. Oxygen administration is the immediate life-saving measure.
• Option D: A comfortable position, such as high-Fowler's, helps ease the work of breathing but does not correct the life-threatening lack of oxygen.

Related Visual

Clinical Relevance

• Nursing practice connection: Prioritize focused assessment, early escalation, and real-time monitoring when managing Priority nursing interventions for status asthmaticus in acute care settings.
• In any patient with respiratory distress, a change in mental status (restlessness, irritability, confusion, lethargy) is an ominous sign of hypoxia and requires immediate oxygen administration.
• A 'silent chest' (absence of wheezing) during a severe asthma attack is a critical finding. It indicates minimal to no air movement and signals impending respiratory failure, requiring immediate preparation for intubation.
• What if? If the patient were alert and oriented with an oxygen saturation of 95% but still wheezing significantly, the priority would shift to administering a fast-acting bronchodilator, as immediate life-threatening hypoxia would not be the primary concern.

How to Approach the Question

• First, identify the patient's condition as a medical emergency: status asthmaticus.
• Next, analyze the signs and symptoms to find the most critical clue. In this case, 'irritability' is a sign of altered mental status, pointing directly to cerebral hypoxia.
• Apply the ABC (Airway, Breathing, Circulation) framework to prioritize interventions. The patient's breathing is severely compromised, making it the highest priority.
• Evaluate each option based on the ABCs. The action that most directly and immediately addresses the life-threatening breathing problem (hypoxia) is the correct choice.
• Starting oxygen directly treats the hypoxia. Other actions like giving medications or changing position are important but are secondary to ensuring the brain and vital organs are oxygenated.

Concept Tested & Keywords

• Concept Tested: Priority nursing interventions for status asthmaticus
• Stem keywords: status asthmaticus, tachypnea, laboured respiration, tachycardia, elevated blood pressure, irritable
• Lead-in keywords: What will nurse do
• Clinical cues: Irritability: This is a critical sign indicating cerebral hypoxia, a life-threatening complication that requires immediate intervention.
• Negative lead-in flag: false

Question ID

Q6NnPBgjOvrVeWaiO1y59V

Copy ID

Reference Book

E6 Nursing Brunner Adult Health 3SA Vol 1 Part 2 pp. 59-61, 60-62

E6 Ghai Essential Pediatrics(pp 26-904 of 913) p. 415-417