Which of the following assessment is expected by the nurse for a patient with acute asthmatic attack?

WCL Staff Nurse - 2019

Medical Surgical Nursing

Easy

Appeared in: WCL Staff Nurse - 2019

Explanation

Asthma is a chronic inflammatory disease that causes airway hyperresponsiveness, leading to bronchoconstriction (narrowing of the airways).
During an acute attack, air being forced through these narrowed passages creates turbulent flow, resulting in a high-pitched whistling sound called a wheeze.
This wheezing is most characteristically heard during expiration because the airways naturally become slightly narrower when breathing out, exacerbating the effect of the obstruction.
Therefore, a diffuse expiratory wheeze is considered a hallmark clinical manifestation of an acute asthma attack.

Option B: The cough in asthma is typically dry, spasmodic, and non-productive. A loose, productive cough that brings up sputum is more suggestive of an infectious process like bronchitis or pneumonia.
Option C: This indicates a severe, life-threatening exacerbation known as status asthmaticus, where the airways do not respond to initial bronchodilator treatment. It is a sign of severity, not the initial expected finding in a typical attack.
Option D: Fever and chills are systemic signs of infection and are not direct symptoms of an asthma attack. While an infection can trigger an asthma exacerbation, these signs point to the trigger, not the asthma itself.

Clinical Relevance

Nursing practice connection: Use the key finding related to Assessment of Acute Asthma Exacerbation to guide bedside assessment, documentation, and the next nursing action.
Auscultating for wheezing is a fundamental nursing assessment for any patient presenting with respiratory distress to help differentiate conditions like asthma.
The nurse's assessment must also include respiratory rate, use of accessory muscles, oxygen saturation (SpO₂), and the patient's ability to speak in full sentences.
What if? If the nurse auscultates the chest of a patient in severe distress and hears no wheezing, this is a 'silent chest.' This is an ominous sign of impending respiratory failure because airflow is too restricted to generate sound. It requires immediate emergency intervention.

How to Approach the Question

First, identify the core of the question, which asks for the expected or classic sign of an acute asthmatic attack.
Recall the basic pathophysiology of asthma: bronchoconstriction, inflammation, and mucus production lead to narrowed airways.
Think about the sound air makes when forced through a narrow tube—it whistles. This is a wheeze.
Consider the respiratory cycle. Airways are naturally narrower on expiration, so the wheeze will be most prominent then.
Evaluate each option based on this core pathophysiology. 'Diffuse expiratory wheeze' directly matches this process.
Rule out the other options by identifying what they represent: infection (productive cough, fever) or a severe complication (no relief from inhalant), which are not the primary expected signs.

Concept Tested & Keywords

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