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: In this scenario, the correct answer is option C: Use of accessory muscles in breathing. This finding indicates that the patient is experiencing severe respiratory distress, a critical situation that requires immediate nursing intervention. When a patient with a history of asthma begins to use accessory muscles to breathe, it suggests that their respiratory effort is significantly increased in order to maintain adequate oxygenation. Option A, a pulse oximetry reading of 91%, though below the normal range, does not convey the urgency of the situation like the use of accessory muscles does. Option B, a respiratory rate of 26 breaths/min, while elevated, may not always indicate immediate distress. Option D, a peak expiratory flow rate of 240 L/min, is within normal limits for some individuals with asthma and does not necessarily signal an urgent need for intervention. Educationally, it is crucial for nurses to recognize and respond promptly to signs of respiratory distress in patients with asthma, as it can escalate rapidly and lead to life-threatening complications. Understanding the significance of using accessory muscles in breathing can help nurses prioritize care and intervene effectively to prevent respiratory failure in asthmatic patients.

Correct Answer: B

Rationale: The correct answer is B) Independently caring for the tube. This option is correct because when a patient with a laryngectomy is able to independently care for their laryngectomy tube, it indicates a sense of regained control over their personal care. This autonomy and self-sufficiency are positive signs that the patient's hopelessness is being resolved. It demonstrates that the patient is actively engaging in their own care and taking steps towards recovery and adaptation to their new situation. Option A) Requesting no visitors suggests a desire for isolation, which can be a sign of continued hopelessness as the patient may be withdrawing from social interactions and support. Option C) Letting the nurse provide care may indicate a lack of motivation or willingness to participate in their own care, which can be a sign of ongoing hopelessness. Option D) Relying on the spouse for care may indicate a dependency that can perpetuate feelings of helplessness and hopelessness in the patient. In an educational context, understanding how to assess indicators of hopelessness in patients undergoing significant medical procedures like a laryngectomy is crucial for nurses and healthcare providers. Recognizing signs of hopelessness allows for timely interventions and support to help patients cope and adapt to their new condition. Encouraging patient autonomy and self-care activities can be empowering and therapeutic in promoting a sense of control and well-being in patients facing challenging health situations.

Correct Answer: A

Rationale: The correct answer is A) Isoniazid, rifampin, and pyrazinamide. Noninfectious hepatitis is a known toxic effect of these TB medications. Isoniazid, rifampin, and pyrazinamide are commonly used in combination for the treatment of tuberculosis. Option B) Ethambutol only, and option C) Rifampin only are incorrect because noninfectious hepatitis is not associated with these medications. Ethambutol is known to cause optic neuritis, while rifampin is associated with red-orange discoloration of body fluids. Option D) None of the above is incorrect as the combination of isoniazid, rifampin, and pyrazinamide is indeed linked to noninfectious hepatitis. It is crucial for nursing students to understand the potential adverse effects of medications used in the treatment of tuberculosis to provide safe and effective care to patients. Recognizing these side effects can help in early detection and appropriate management to prevent further complications.

Correct Answer: D

Rationale: In this scenario, the correct answer is option D) Risk for infection. The priority nursing diagnosis for a patient with low O2 saturation is assessing and addressing the risk for infection. When a patient has low O2 saturation, it indicates that all body tissues are not receiving adequate oxygen, making them more susceptible to infections due to compromised immunity. Choosing option D as the priority nursing diagnosis is crucial because infections can further compromise the body's ability to oxygenate tissues, worsening the existing oxygenation problem. By addressing the risk for infection, nurses can help prevent potential complications that could exacerbate the patient's condition. Options A, B, and C are incorrect in this context because while impaired gas exchange, ineffective breathing, and pain are important nursing diagnoses to consider for a patient with low O2 saturation, addressing the risk for infection takes precedence due to the potential for further deterioration of the patient's condition. Educationally, understanding the priority nursing diagnosis in a situation like this is essential for providing safe and effective patient care. It highlights the importance of critical thinking in prioritizing patient needs based on the assessment data. By recognizing the significance of addressing the risk for infection in a patient with low O2 saturation, nurses can intervene early to prevent complications and promote optimal patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) α1-antitrypsin deficiency. In young patients with COPD and no smoking history, the suspicion should be on genetic factors, particularly α1-antitrypsin deficiency. This genetic condition predisposes individuals to early-onset COPD even in the absence of smoking. Option B) Nicotine addiction is incorrect because the patient has no smoking history, making nicotine addiction unlikely. Option C) Pulse oximetry need is incorrect as it does not address the underlying cause of COPD in a young non-smoking patient. Option D) Asthma diagnosis is incorrect because COPD and asthma are distinct conditions with different pathophysiology. Educationally, understanding the etiology of COPD in young non-smokers is crucial for accurate diagnosis and appropriate management. Recognizing the role of genetic factors like α1-antitrypsin deficiency in such cases is essential for providing targeted care and genetic counseling. This question highlights the importance of considering alternative causes of COPD beyond smoking, enhancing critical thinking skills for healthcare professionals.