The nurse assesses a patient with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?

Correct Answer: C

Rationale: Accessory muscle use signals severe respiratory distress, requiring urgent intervention.

Correct Answer: B

Rationale: Independently caring for the laryngectomy tube indicates that the patient has regained control of personal care and hopelessness is at least partially resolved. Letting the nurse and spouse provide care and requesting no visitors may indicate that the patient is still experiencing hopelessness.

Correct Answer: A

Rationale: Noninfectious hepatitis is a toxic effect of isoniazid, rifampin, and pyrazinamide, and patients who develop hepatotoxicity will need to use other medications. Changes in hearing and nail thickening are not expected with the four medications used for initial TB drug therapy.

Correct Answer: D

Rationale: All of these nursing diagnoses are appropriate for the patient, but the patient's O2 saturation indicates that all body tissues are at risk for hypoxia unless the gas exchange is improved.

Correct Answer: A

Rationale: When COPD occurs in young patients, especially without a smoking history, a genetic deficiency in α1-antitrypsin should be suspected. Because the patient does not smoke, a nicotine patch would not be ordered.