HESI: Asthma and Rationale

25. The child returns home. He and his caregiver participate in the asthma education program at the primary healthcare provider's (HCP's) clinic. During the session on environmental triggers, his caregiver tells the nurse that he now has a pet. Which strategies should the nurse discuss with the the caregivers to reduce exposure to airborne allergens in the home?

-Focus on eliminating dust in the room where the child sleeps. (Rationale: Children with asthma should avoid triggers such as dust, dust mites, and mold.) -Use acetaminophen as an antipyretic. (Rationale: Approximately 2-6% of children with asthma are sensitive to acetylsalicylic acid (aspirin) therefore, the caregivers should be cautioned to avoid medications with an acetylsalicylic acid component.) -Monitor for the presence of tartrazine in medicines. (Rationale: Approximately 2-6% of children with asthma are sensitive to acetylsalicylic acid (aspirin) therefore, caregivers should be cautioned to avoid medications with an acetylsalicylic acid component. Children with acetylsalicylic acid sensitivity may also be sensitive to NSAIDs and tartrazine (yellow dye number 5), a common food coloring.)

21. What are the client education priorities during the acute care phase?

-How to use inhaled bronchodilators and corticosteroids. (Improper inhaler technique can result in up to a 65% loss of delivery of medication to the lungs. It is critical he receive his entire medication dose.) -Parental recognition of early warning signs. (Exacerbations respond to treatment best if treatment starts at the earliest warning sign.) -Identify potential allergens in the home. (Asthma education is an important component of the nursing care of children hospitalized with asthma.) -Reducing the risk of upper respiratory tract infections. (This was the precipitating cause of the current admission, so it must be addressed. Upper respiratory tract infections are the cause of the most severe exacerbations in children.)

10. The child's asthma appears to be under control until November when the weather temperature suddenly drops. He develops an upper respiratory tract infection, which triggers a severe asthma exacerbation. He presents to the Emergency Department (ED). He is clinging to his caregiver, sitting leaning forward, and refuses to lie down. Which assessment findings would alert the nurse that the child is in respiratory distress?

-Inability to speak without gasping. (Narrowing of airways prevents ability to speak, resulting in gasping.) -Refusal to lie flat. (Lying flat places more pressure on the chest, making it harder to breathe.) -Presence of subcostal retractions. (Subcostal retractions occur when the muscles between the ribs pull inward. The movement is most often a sign that the person has a breathing problem.) -Absence of wheezing with increased respiratory rate. (Absence of wheezing in an asthmatic may indicate either improvement of the bronchoconstriction or severe, widespread airflow obstruction.)

11. Based on the child's presentation, the nurse suspects status asthmaticus. Which nursing interventions should be implemented?

-Monitor saturation. (Oxygen saturation provides information on oxygenation status.) -Initiate oxygen therapy. (Oxygen therapy helps to correct hypoxemia.) -Start an IV. (Intravenous access is needed for hydration and medication administration.)

1. The school nurse's observations of the child include the following: absence of fever or sore throat, persistent dry cough, wheezing, exercise intolerance, and a history of resolution of symptoms after β2-agonists treatments in the emergency department (ED). Which of the school nurse's observations are consistent with the diagnosis of bronchitis?

A dry cough that becomes productive. A dry, hacking cough that becomes productive in 2 to 3 days is characteristic of bronchitis. The cough associated with asthma is nonproductive.

14. The child is to be transferred to the acute care unit. The ED nurse prepares report. In preparing the SBAR report related to this ED visit, what are the priority data points that the ED nurse must communicate?

Acute asthma exacerbation precipitated by an upper respiratory infection, PEFR reading, medications given with response to treatment, and respiratory assessment. (Educating about the trigger that caused the present exacerbation is an educational priority for hospital-based care. Current PEFR reading, respiratory assessments, and response to treatment are critical data.)

18. When the child is stabilized, the nurse encourages him to participate in activities in the playroom. He withdraws and says his caregiver doesn't let him go to the playground when he has misbehaved. With careful questioning the nurse learns that he hasn't been washing his hands as directed at school. He feels responsible for catching the cold that caused this exacerbation. Using knowledge of child development, the nurse interprets his behavior according to which description?

Appropriate for age in a preschooler. Rationale: The preschooler's inability to logically reason the cause and effect of illness or injury makes it difficult for them to understand such events. Their thinking is often described as "magical thinking." According to Erikson, preschoolers are developing a sense of initiative versus guilt. Guilt is a normal reaction to overstepping rules at this age.

20. The caregiver is fearful and distraught over the occurrence of this asthma exacerbation. The caregiver asks the nurse, "When will he outgrow his asthma?" Based on knowledge of asthma as a chronic inflammatory disease, in this case complicated by allergic rhinitis, what is the best response by the nurse?

Asthma is not truly outgrown, but symptom management increases the quality of life. Rationale: Asthma is a chronic inflammatory disease, and never truly goes away. This message focuses on giving the caregiver a sense of control. Asthma self-management and self-care are important components of coping with asthma. Attention to drug therapy, exacerbation prevention, environmental control, and management skills should be included in education for the child and family. Children with asthma can live a full and active life.

4. In developing plan of care goals, the school nurse recognizes what level of activity is appropriate for children with asthma?

Children with asthma should participate fully in all activities if they are in the green zone. The National Asthma Education and Prevention Program, which sets standards for the management of asthma, states this as a primary goal of care:Exercise is advantageous for children with asthma, and most children can participate in activities at school and in sports with minimal difficulty, provided their asthma is under control. The green zone is indicative of 80-100% of a child's personal best, which signals that asthma is under reasonably good control.

23. The asthma educator wants to assure the child's caregiver should increase asthma controller treatment at the earliest sign of an exacerbation. To empower the caregiver to do this, the educator realizes the child's caregiver must detect early warning signs of an impending attack. The nurse should stress which of the following as early signs of an impending asthma attack?

Complaint of prodromal itching in the neck area. Rationale: Classic manifestations of asthma include dyspnea, wheezing, and coughing. Older children may complain of chest tightness and an intermittent generalized chest pain. Children may experience a prodromal itching localized at the front of the neck or over the upper part of the back. An asthmatic episode usually begins with children feeling uncomfortable or irritable and increasingly restless. They may also complain of having a headache, feeling tired, or feeling tightness in the chest. Coughing in the middle of the night is an early warning sign that asthma is not in good control.

24. The nurse recognizes it is critical for the child to have medication on hand. A common clinical problem is incorrect assessment of the level of medication left in the inhaler, resulting in lack of on-hand medication. Which is the correct method of assessing the level of medication in the inhaler?

Count the number of inhalations used. Rationale: Children and families should be taught the product label to see how many inhalations should be in each canister. Some of the metered dose inhalers have a dose counting device to specify the remaining number of doses available in the canister.

7. The school nurse observes 60 of the 120 salbutamol MDI actuations are used within the first 2 weeks of therapy. The child's prescribed dose is two puffs before exercise on school days and two puffs when needed for acute symptoms. According to the Rule of Two* rescue inhalers should not be refilled more than two times a year. Based on the nurse's knowledge of this medication, what is the next action?

Discuss the treatment plan with his caregiver and emphasize the benefits of controller medication. Children with asthma should have a home action plan. This action plan should include the three peak flow zones and medications, including rescue and maintenance medications. The number of the healthcare provider should be readily available for medication requests. The caregiver and child should be cautioned about the dangers of overusage of β2-agonists, and that these medications are not to be used indiscriminately or as a substitute for avoiding symptom-provoking allergens.

19. The nurse recognizes that play is one of the most effective ways of managing stress in hospitalized children. Which is an appropriate play activity for the child to express his feelings?

Drawing and painting. Rationale: For the child of this age, the imaginative mind enjoys playing for play's sake. Toys and play should include manipulation, constructive, and creative opportunities. Examples include easy construction sets, blocks of various sizes and shapes, alphabet or number flash cards, paints, crayons, puzzles, illustrated books, large puzzles, and clay. Drawing and painting are excellent expressive activities. They can also be used to facilitate communication with the child.

17. What are the highest priority acute care nursing interventions for the nurse to include in the child's plan of care?

Frequent respiratory assessment, vital signs, and pulse oximetry monitoring. Rationale: Children should be monitored closely and continuously for relief of respiratory distress (especially after corticosteroids, beta agonists and oxygen therapy). Pulse oximetry is monitored along with the rate and depth of breathing, auscultation of air movement, and any signs of respiratory distress.

6. The school nurse recognizes that goals for symptom control may not be achieved unless proper inhaler technique is used. She observes the child using his metered dose inhaler (MDI) prior to recess. The school nurse recognizes the child is using correct inhaler technique by observing which demonstration?

He holds his breath for 10 seconds after inhaling the medication. Holding the breath for 5 to 10 seconds after inhalation enhances medication delivery to the lungs.

16. Which nursing diagnoses best describes the underlying pathophysiologic process for a child with an acute asthma exacerbation?

Ineffective airway clearance related to inflammation and constriction of the bronchial tree. Rationale: The mechanisms of asthma include inflammatory response to stimuli, airway edema and accumulation of mucus, spasm of smooth muscle of the bronchi and bronchioles, and airway remodeling.

5. The school nurse recognizes the child's symptoms worsen in the classroom after he naps on the floor mats. What measures can the school nurse take to ensure a trigger-free classroom environment?

Initiate measures to eliminate all sources of dust in the classroom. One goal of asthma management is avoidance of irritants and allergens. House dust mites and other components of dust are frequently identified as triggers. Other triggers include cockroaches, cats, dogs, tobacco smoke, cleaning products, pesticides, and mold.

12. The child receives an initial dose of inhaled salbutamol and orders are to repeat this treatment every 20 minutes times two. His condition is not improving. What additional emergency medication should the nurse anticipate preparing?

Magnesium sulfate IV. Therapies in acute asthma attacks include medications to decrease inflammation. Magnesium sulfate IV, a potent muscle relaxant, decreases inflammation and improves pulmonary function and peak flow rate in children when treated in the ED or ICU.

3. The child fails to adhere to the proper administration of his asthma medication and experiences symptoms of moderate persistent asthma. Based on the Asthma Classification in Children which symptoms would be expected to occur?

Night time cough more than once a week but not nightly. Nocturnal cough more than once a week is a feature of moderate, persistent asthma as are daily symptoms and interference with physical activity. A common symptom of asthma is coughing in the absence of a respiratory tract infection, especially at night.

2. The school nurse asks the child's caregiver to take him to a healthcare provider (HCP) to evaluate his respiratory problem. After pulmonary function testing is performed, it is determined he has moderate persistent asthma and allergic rhinitis. He returns to school with a note from his caregiver stating he may not participate in recess on the playground. The child's caregiver asks the school nurse to explain the pulmonary function test. Which of the following information is accurate?

Pulmonary function tests are used to detect airflow limitation even when no symptoms are clinically evident. Symptoms in children with asthma are typically seasonal or nocturnal and are often not evident on physical examination. Pulmonary function tests are able used to detect effects of airway inflammation that may otherwise be undetectable.

8. The school nurse monitors the child for response to salbutamol. What response might the nurse expect to observe?

Rapid heart rate. Common adverse effects of salbutamol include palpitations, tachycardia, dry nose, tremors, anxiety, headache, dizziness, nausea, and irritability.

22. The nurse requests the child's caregivers meet with the asthma educator. One of the child's caregivers attends the class. The second caregiver is not attending because this person does not believe the child has asthma. The child splits his time between two caregivers. The caregivers have a positive relationship with the primary pediatric healthcare provider (HCP). Which is the best intervention for the nurse to implement to assure partnership with both caregivers and continuity of care?

Request an educational session with both caregivers in the primary pediatric care setting. Rationale: The short- and long-term adaptation of children with asthma often depends on the the caregiver's acceptance of the disorder. The task of managing asthma day to day involves the entire family. The potential for periodic crises and management can be stressful. During these periods, families needs support and encouragement to continue to promote as normal a life for the child as possible. The goal of care is to foster partnership with the caregivers. The second caregiver's response is not uncommon and is often amenable to education from a trusted healthcare provider (HCP).

26. The child's caregiver tells the nurse a neighbor's child who has asthma uses salmeterol xinafoate, a long-acting β2-agonist. The caregiver would like to replace the client's salbutamol with this medication because he may need to use his inhaler less frequently. The response by the nurse is based on what knowledge about salmeterol xinafoate?

Salmeterol xinafoate cannot be used to treat acute symptoms. Salmeterol xinafoate is added to anti-inflammatory therapy and is used for long-term prevention of symptoms. Although salmeterol xinafoate is a bronchodilator, it can only be administered every 12 hours and is not to be used as a rescue medication.

9. The nurse notices the child is anxious. Since anxiety can promote bronchoconstriction, the nurse will teach him controlled breathing exercises. The nurse determines that a gaming strategy will be the best way to teach a child controlled breathing. Which intervention is best for the nurse to implement?

Teach him to blow a pinwheel. This is a developmentally appropriate strategy. Activities that promote diaphragmatic breathing, side expansion, and improved mobility of the chest wall include blowing cotton balls, blowing a ping pong ball, blowing a pinwheel, blowing bubbles, or preventing a tissue from falling by blowing it against a wall.

13. The nurse in the ED monitors the child's peak expiratory flow rate (PEFR; maximal expiratory flow in 1 second). His personal best is 180 L/second. On initial presentation, he was unable to initiate a blast into the peak flow meter. After the third treatment with albuterol, he is able to blow 85 L/second. Which is a correct interpretation of the child's current PEFR reading?

The child is in the red zone. There is severe airway narrowing. Rationale: The red zone signifies less than 50% of the child's personal best. This is a medical emergency because it signifies that airway narrowing may be occurring. The yellow zone signifies 50-79% of the personal best and indicates that the asthma is not well controlled and an acute exacerbation could occur. The green zone is 80-100% of the child's personal best and indicates that the asthma is under reasonably good control.

15. The acute care nurse prepares a plan of care for the child and his caregiver. Which disciplines should be involved in developing an asthma action plan for the child?

The healthcare provider (HCP), nurse, and parents. Rationale: The overall goals of asthma management are to minimize complications and maximize function. Actions include regular visits to the HCP, prevention of exacerbations, and initiating therapies to control symptoms and prevent/manage attacks.