Health Promotion and Maintenance
18. A child arrives in an emergency department with a chief complaint of asthma exacerbation. Which assessment information is most important for the nurse to obtain first?
Health Promotion and Maintenance
18. A child arrives in an emergency department with a chief complaint of asthma exacerbation. Which assessment information is most important for the nurse to obtain first?
. Whether the child has been taking asthma medications as prescribed.
. When the child began having symptoms.
. Whether the child is able to speak in full sentences.
. The child's ABG levels.
Test-Taking Tip
The question asks what the nurse should do first. Remember the nursing process–first assess the ABCs (airway, breathing, circulation). The other three responses contain information that could be obtained subsequent to the initial physical assessment.
Content Area: Child Health, Respiratory; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
Health Promotion and Maintenance
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Answer 1 is incorrect because knowing whether the child has been taking medications is not part of the initial physical assessment. Answer 2 is incorrect because knowing when the child began having symptoms is not part of the initial physical assessment. Answer 3 is correct because the nurse should first assess the child's airway to determine the severity of respiratory symptoms. One way to assess shortness of breath is to determine whether the child speaks in full sentences, short phrases, or barely at all. Answer 4 is incorrect because the nurse should first assess the airway. ABGs (arterial blood gases) may be obtained later if ordered by the practitioner.