A 2-year-old boy arrives at the emergency department of a local hospital with difficulty breathing from an asthmatic attack. Which of the following would be the priority nursing intervention?

Correct Answer: B

Rationale: The correct answer is B because assessing respirations and administering oxygen is the priority nursing intervention in a 2-year-old boy with difficulty breathing from an asthmatic attack. This step is crucial in managing respiratory distress and ensuring adequate oxygenation. Stuffed animal (choice A) may provide comfort but does not address the immediate respiratory issue. Raising side rails and restraining arms (choice C) may escalate anxiety and worsen breathing difficulties. Asking about favorite foods (choice D) is irrelevant in the acute management of asthma exacerbation. Prioritizing respiratory assessment and oxygen administration is essential for the child's well-being and should be the initial focus.

Correct Answer: A

Rationale: The correct answer is A because it violates the patient's privacy and confidentiality by exposing them inappropriately. HIPAA regulations protect patient privacy, requiring appropriate gowning during ambulation. Choices B and C involve patient care issues, not HIPAA violations. Choice D violates patient privacy but does not involve a direct breach like choice A.

Correct Answer: B

Rationale: Developing a teaching plan is comparable to formulating a nursing care plan because both involve assessing the patient's needs, setting goals, planning interventions, and evaluating outcomes. Teaching plans focus on educating patients, while nursing care plans address the overall care and management of the patient. Documenting in the nurse's notes (A) is important but does not involve the same level of planning and detail as developing a teaching plan. Performing a complex technical skill (C) requires specific hands-on abilities rather than planning and organizing information. Using a standardized form or format (D) may provide structure but does not encompass the individualized approach necessary for developing a teaching plan.

Correct Answer: D

Rationale: The correct answer is D: Displacement. Displacement is the defense mechanism where emotions or impulses are redirected from the original target to a less threatening target. In this scenario, the patient is displacing their anger from their spouse onto the nurse. This is evident by the patient becoming verbally abusive towards the nurse after the argument with their spouse. A: Denial is the defense mechanism where individuals refuse to accept reality. This is not applicable in this situation as the patient is not denying the argument with their spouse. B: Projection is the defense mechanism where individuals attribute their own unacceptable thoughts or feelings onto someone else. This is not the case here as the patient is not attributing their behavior to the nurse. C: Sublimation is the defense mechanism where individuals channel their emotions into more socially acceptable behaviors. This is not relevant in this context as the patient is not channeling their emotions into a constructive outlet.

Correct Answer: A

Rationale: The correct answer is A: Chronic grief. Chronic grief occurs when an individual experiences long-lasting and unresolved grief over an extended period of time. In this scenario, the wife is still grieving her deceased husband after five years, indicating a prolonged and ongoing grief process. Delayed grief (B) refers to a postponed emotional response, which is not the case here as the grief has been ongoing. Masked grief (C) involves displaying symptoms of grief in other ways, without acknowledging the underlying loss, which is not evident in this situation. Uncomplicated grief (D) refers to a typical, expected response to loss without any complicating factors, which may not be the case for the wife still grieving after five years.