Which nursing action is most appropriate for the weak patient with osteoporosis?

Correct Answer: B

Rationale: For a weak patient with osteoporosis, it is important to promote mobility and weight-bearing activities to help maintain bone strength and prevent further bone loss. Ambulating with assistance can help improve muscle strength and balance, reducing the risk of falls and fractures. Maintaining bedrest can lead to further weakness and bone loss, so it is not the most appropriate action in this case. Encouraging fluids and providing a high-protein diet are important for overall health and healing but might not directly address the specific needs of a weak patient with osteoporosis.

Correct Answer: B

Rationale: The best explanation of emphysema for a newly diagnosed patient is that "Your lungs have lost some of their elasticity, and air gets trapped." This explanation succinctly captures the key characteristic of emphysema, which is the destruction of the alveoli in the lungs leading to the loss of elasticity. When the alveoli lose their elasticity, they are not able to effectively expel air during exhalation, causing air to become trapped in the lungs. This trapped air leads to difficulty breathing, shortness of breath, and other respiratory symptoms commonly associated with emphysema. This explanation is clear and focuses on the primary pathology of emphysema, making it the most appropriate choice for a newly diagnosed patient to understand their condition.

Correct Answer: A

Rationale: Pursed lip breathing is a breathing technique commonly used to help improve breathing efficiency in individuals with respiratory conditions such as chronic obstructive pulmonary disease (COPD). By pursing the lips during exhalation, it creates back pressure that helps to keep the airways open longer. This results in slower and more controlled expiration, allowing the individual to exhale a smaller volume of air while maintaining adequate oxygen exchange. This can reduce the feeling of dyspnea (difficulty breathing) and help improve oxygen saturation levels in the blood.

Correct Answer: C

Rationale: Dyspnea, or difficulty breathing, may be the first abnormal sign detected in a client with cardiomyopathy. Cardiomyopathy is a disease of the heart muscle, which can lead to impaired heart function. As the heart's ability to pump blood effectively is compromised, the body may not receive an adequate supply of oxygen-rich blood. This can result in symptoms such as dyspnea, especially during physical exertion or when lying down. Ascites (fluid accumulation in the abdomen), chest pain, and heart murmur may also be seen in clients with cardiomyopathy but are not typically the first signs to present. Dyspnea is often a key indicator that should prompt further evaluation and monitoring for cardiac issues.

Correct Answer: A

Rationale: Epinephrine is the medication of choice for anaphylaxis. Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, airway constriction, and other serious symptoms. Epinephrine acts quickly to reverse these symptoms by constricting blood vessels, relaxing the muscles in the airways, and increasing heart rate. It is administered via an auto-injector device, such as an EpiPen, in cases of severe allergic reactions. Other medications, such as antihistamines and corticosteroids, may be given as adjunct therapy, but epinephrine is the first-line treatment for anaphylaxis. Thus, the nurse should anticipate that epinephrine would be ordered for a patient experiencing anaphylaxis.