Explanation

In a severe asthma exacerbation, decreased wheezing accompanied by diminished or absent breath sounds is an ominous sign. It indicates a significant decrease in airflow due to severe bronchoconstriction and airway obstruction, potentially leading to respiratory failure. While wheezing is a common finding in asthma, its absence in a client with respiratory distress suggests the airways are so constricted that little to no air is moving.

Increased use of accessory muscles indicates increased work of breathing but is common during exacerbations and doesn't necessarily signify the most severe worsening compared to absent breath sounds. A PEFR of 60% indicates a moderate exacerbation but is better than values below 50%. A productive cough may be present but is less indicative of acute worsening airflow obstruction than absent breath sounds.