A patient who had a total laryngectomy has a nursing diagnosis of hopelessness related to loss of control of personal care. Which information obtained by the nurse indicates that this identified problem is resolving?

Correct Answer: C

Rationale: In this scenario, option C is the correct answer. When the patient asks how to clean the tracheostomy stoma and tube, it indicates that the identified problem of hopelessness related to loss of control of personal care is resolving. This question assesses the patient's willingness to engage in self-care activities, demonstrating a return of autonomy and a sense of empowerment. Option A is incorrect because allowing the nurse to suction the tracheostomy does not necessarily reflect the patient's initiative in self-care. Option B is incorrect as reliance on the spouse for daily tracheostomy care does not indicate the patient's independence in managing personal care needs. Option D is also incorrect as using a communication board to request 'No Visitors' does not address the self-care aspect or reflect a positive change in the patient's attitude towards personal care. From an educational perspective, this question highlights the importance of assessing a patient's psychological response to physical changes and loss of control. It emphasizes the nurse's role in promoting patient independence and empowerment in self-care activities to enhance the patient's overall well-being and quality of life. Encouraging patients to ask questions and participate in their care can have a significant impact on their recovery and emotional state.

Correct Answer: D

Rationale: The priority nursing diagnosis in this scenario is "D) Impaired gas exchange related to respiratory congestion." Rationale: Impaired gas exchange is the priority because the patient's O₂ saturation is only 88%, indicating inadequate oxygenation. This poses a serious threat to the patient's health and needs immediate intervention to prevent hypoxia and further complications like respiratory failure. Why others are wrong: A) Hyperthermia related to infectious illness: While fever is present, it is not the immediate threat to the patient's well-being. Oxygenation takes precedence over managing fever. B) Impaired transfer ability related to weakness: While weakness is a concern, it is secondary to the critical issue of impaired gas exchange affecting oxygen delivery to vital organs. C) Ineffective airway clearance related to thick secretions: While this is important, the priority is to ensure that the patient is able to oxygenate adequately to support vital functions. Educational context: Understanding the prioritization of nursing diagnoses is crucial in providing effective and efficient patient care. In acute situations like respiratory distress, addressing impaired gas exchange promptly can make a significant impact on patient outcomes. Nurses must be able to differentiate between urgent and non-urgent issues to prioritize care effectively and ensure patient safety.

Correct Answer: D

Rationale: The correct answer is D) The patient uses an albuterol (Ventolin HFA) inhaler for peak flows in the yellow zone. This answer is correct because using albuterol in the yellow zone indicates appropriate self-management of asthma exacerbation. Albuterol is a rescue medication that helps to open up the airways quickly during an asthma attack or when peak flow readings drop into the yellow zone, signaling a cautionary phase. Option A is incorrect because inhaling rapidly through the peak flow meter mouthpiece does not reflect proper technique. Option B is incorrect as montelukast is a long-term control medication and is not typically used for immediate symptom relief in the red zone. Option C is also incorrect as calling the healthcare provider when in the green zone is unnecessary as this zone indicates good lung function. Understanding peak flow meter readings and knowing how to respond appropriately based on the zones is crucial in managing asthma effectively. Educating patients on using rescue medications like albuterol in the yellow zone can help prevent asthma exacerbations and improve overall respiratory health.

Correct Answer: D

Rationale: The correct answer is D because the patient's asthma is not well-controlled with only short-acting bronchodilators like albuterol (Ventolin HFA) and long-acting bronchodilators like salmeterol (Serevent). This combination does not address the underlying inflammation in asthma. The patient needs an inhaled corticosteroid as maintenance therapy to control inflammation and prevent exacerbations. Option A is incorrect because using albuterol before exercise is a common practice to prevent exercise-induced bronchospasm in asthma patients. Option B is incorrect because worsening symptoms in spring could be related to seasonal allergens triggering asthma, which may require adjustment in therapy, but it does not necessarily indicate a need for an immediate change. Option C is incorrect because an increase in heart rate after using albuterol is an expected side effect due to its bronchodilator properties and does not necessarily indicate a need for a change in therapy unless there are other concerning symptoms present. In an educational context, it is vital for nurses to understand asthma management principles to provide optimal care for patients. Recognizing when a patient's current therapy is inadequate and needs adjustment is crucial in preventing asthma exacerbations and improving quality of life. Incorporating evidence-based guidelines in asthma management helps nurses make informed decisions in patient care.

Correct Answer: D

Rationale: To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as '99.' After noting absent fremitus, the nurse should then auscultate the lungs to assess for the presence or absence of breath sounds. Absent fremitus may be noted with pneumothorax or atelectasis. The vibration is increased in conditions such as pneumonia, lung tumors, thick bronchial secretions, and pleural effusion.