A patient receiving palliative care for end-stage lung disease experiences dyspnea and anxiety. What intervention should the palliative nurse prioritize to address the patient's symptoms?

Correct Answer: B

Rationale: Teaching the patient diaphragmatic breathing exercises for respiratory support would be the most appropriate intervention to address the symptoms of dyspnea and anxiety in this scenario. Diaphragmatic breathing, also known as belly breathing, focuses on engaging the diaphragm for deep, slow breaths, which can help improve lung expansion and ventilation. This technique can help the patient manage their breathing difficulty and reduce anxiety by promoting relaxation and improving oxygen exchange in the lungs. It empowers the patient with a coping strategy they can use independently to alleviate distressing symptoms at any time. Administering oxygen therapy may be beneficial, but the priority is to teach the patient a technique they can use proactively and routinely. Prescribing benzodiazepines should be considered as an adjunct if non-pharmacological interventions are ineffective in managing anxiety. Referring to a pulmonologist may be necessary for comprehensive evaluation and treatment but may not directly address the immediate symptoms of dyspnea and anxiety.

Correct Answer: C

Rationale: Rabies has a shorter incubation period if the bite is located on the hand. This is because bites on the hand are more likely to have direct access to nerve pathways, which can lead to a faster spread of the rabies virus to the central nervous system. In general, bites on parts of the body closer to the brain and spinal cord, such as the hand and face, can result in a quicker onset of rabies symptoms compared to bites on farther extremities like the leg or abdomen.

Correct Answer: A

Rationale: In the case of a woman in active labor with placenta previa, the priority nursing intervention is to prepare for an immediate cesarean section. Placenta previa is a condition in which the placenta covers part or all of the cervix, which can lead to severe bleeding during labor and delivery. The risk of hemorrhage is significant, making a cesarean section the safest option for both the mother and the baby in this situation. It is crucial to act promptly to prevent complications and ensure the well-being of both the mother and the baby. Administering intravenous oxytocin to augment labor or inserting a Foley catheter to monitor urine output would not address the immediate risk of hemorrhage associated with placenta previa. Implementing bed rest and continuous fetal monitoring may be part of the overall care plan but not the priority intervention in this urgent situation.

Correct Answer: C

Rationale: In the case of Mang Luis, who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing exacerbation, the most crucial health intervention to include in the teaching plan is to reduce the risk for infection. COPD exacerbations are commonly triggered by respiratory infections such as pneumonia and bronchitis. Preventing infections is essential in managing COPD as they can lead to worsening of symptoms and increased healthcare utilization. Therefore, educating Mang Luis on strategies to reduce the risk of infection, such as proper hand hygiene, avoiding exposure to sick individuals, getting vaccinated, and managing environmental factors, is paramount in his care plan.

Correct Answer: D

Rationale: Addison's disease is a rare endocrine disorder characterized by adrenal insufficiency, leading to a deficiency in cortisol and aldosterone production. The symptoms of Addison's disease include fatigue, weakness, hyperpigmentation of the skin (due to elevated levels of ACTH stimulating melanocytes), and salt craving (due to aldosterone deficiency). Low serum sodium levels and elevated serum potassium levels are also common laboratory findings in Addison's disease, as aldosterone plays a key role in maintaining electrolyte balance. Patients with Addison's disease are at risk of developing an adrenal crisis, which can be life-threatening if not promptly recognized and treated with glucocorticoid and mineralocorticoid replacement therapy.

Correct Answer: A

Rationale: This scenario falls under the category of invasion of privacy. Invasion of privacy occurs when a person's private information or images are shared or used without their consent, leading to an intrusion of their private life. In this case, Kris, as a hospitalized movie star, had her picture taken without permission by the nursing assistant, which was later sold to a local newspaper. Kris has a right to privacy, especially during a vulnerable time like being hospitalized, and the nursing assistant violated that right by taking and selling her picture without consent. This action constitutes an invasion of privacy.

Correct Answer: C

Rationale: The correct answer, C, reflects a health resource problem. The absence of a midwife in the community means that there is a lack of a critical health resource necessary for providing essential health services, especially for pregnant women and infants. This directly impacts the access to healthcare services and can contribute to negative health outcomes, such as high maternal mortality rates. The other options do not directly address a health resource problem but rather focus on specific issues or conflicts within the community.

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.

Correct Answer: B

Rationale: The nurse's best approach to address the patient's fear of pain is to provide accurate information about pain management strategies and options. In doing so, the nurse can help alleviate the patient's concerns by empowering them with knowledge and potential solutions for managing pain during and after the procedure. By acknowledging the patient's fear and addressing it with practical information, the nurse can build trust, reduce anxiety, and create a more supportive and collaborative environment for the patient. Dismissing, ignoring, or invalidating the patient's fear would not be effective in addressing the underlying concerns and could potentially lead to increased distress and resistance to the recommended procedure.