A nurse is developing a plan of care for a client who has COPD.
The nurse should include which of the following interventions in the plan?

Restrict the client's fluid intake to less than 2 liters per day.

Provide the client with a low-protein diet.

Instruct the client to use pursed-lip breathing.

Have the client use the early-morning hours for exercise and activity.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Restricting fluid intake in clients with COPD can lead to thickened secretions, making them more difficult to expectorate. Adequate hydration (typically 2-3 liters per day unless contraindicated) is crucial for maintaining thin, mobile respiratory secretions, which facilitates mucociliary clearance and reduces the risk of mucus plugging and subsequent exacerbations. This restriction would hinder respiratory hygiene.

Choice B rationale

Clients with COPD often experience increased metabolic demands due to the effort of breathing and may be at risk for malnutrition and muscle wasting. A low-protein diet would be detrimental, as protein is essential for maintaining respiratory muscle strength, tissue repair, and immune function. A high-protein, high-calorie diet is often recommended to support their nutritional status and overall health.

Choice C rationale

Pursed-lip breathing is a technique that helps clients with COPD by increasing intrabronchial pressure, which prevents premature airway collapse during exhalation, particularly in those with emphysema. This prolongs exhalation, improves gas exchange by allowing more complete emptying of the lungs, reduces air trapping, and can alleviate dyspnea, improving ventilatory efficiency.

Choice D rationale

For clients with COPD, exercising and engaging in activities during early-morning hours can be problematic. This is often the time when respiratory secretions are most abundant and tenacious due to nocturnal accumulation. Engaging in strenuous activity then can exacerbate dyspnea and increase the risk of bronchospasm or fatigue, making later parts of the day often more suitable for activity.

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Correct Answer is C

Explanation

Choice A rationale

Informing a patient with impaired memory about socially appropriate behavior is generally ineffective as their cognitive deficits hinder their ability to process, retain, and apply this information. Their behavioral challenges often stem from neurological changes rather than a lack of understanding of social norms, leading to frustration for both parties.

Choice B rationale

Assisting with all self-care for a patient with dementia can inadvertently foster dependence and diminish their remaining abilities. Encouraging independence in activities of daily living, even with supervision or partial assistance, is crucial to maintain existing cognitive and functional skills and promote a sense of autonomy and dignity.

Choice C rationale

Maintaining familiar routines of sleep, meals, drug administration, and activities provides a sense of predictability and security for individuals with dementia. This consistency minimizes confusion and agitation by reducing the need to process new information and adapting to changes, thereby supporting cognitive function and emotional well-being.

Choice D rationale

While promoting orientation is important, frequent and repetitive questioning about the day, time, and place can be frustrating and agitating for a patient with significant memory impairment from dementia. Instead, providing subtle environmental cues, consistent verbal reminders, and engaging in reality orientation techniques when appropriate is more beneficial.

A. Instruct the client to blow his nose. B. Tilt the client's head backward. C. Place ice to the bridge of the client's nose. D. Move the client into high-Fowler's position. E. Apply pressure to the nares.

Correct Answer is ["C","E"]

Explanation

Choice A rationale

Instructing the client to blow their nose should be avoided during epistaxis, as it can dislodge any forming clots, exacerbate bleeding, and potentially increase intracranial pressure temporarily, particularly if associated with hypertension. The primary goal is to promote vasoconstriction and clot formation.

Choice B rationale

Tilting the client's head backward is contraindicated during epistaxis because it can cause blood to flow down the posterior pharynx, leading to swallowing of blood, which can irritate the stomach and induce nausea or vomiting. Aspiration of blood is also a potential risk.

Choice C rationale

Applying ice to the bridge of the client's nose causes local vasoconstriction, which helps to reduce blood flow to the area and promote hemostasis. The cold temperature induces reflex vasoconstriction in the nasal vasculature, thereby helping to slow or stop the bleeding.

Choice D rationale

Moving the client into a high-Fowler's position is beneficial as it reduces venous pressure in the head and neck, thereby decreasing blood flow to the nasal vasculature and minimizing bleeding. Gravity assists in lowering hydrostatic pressure in the affected vessels, facilitating clot formation.

Choice E rationale

Applying direct pressure to the nares (soft part of the nose) for at least 10-15 minutes is a fundamental and highly effective first-line intervention for epistaxis. This direct pressure helps to compress the bleeding vessels, allowing for clot formation and cessation of hemorrhage.

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A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

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Correct Answer is C

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Correct Answer is ["C","E"]

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A nurse is developing a plan of care for a client who has COPD.
The nurse should include which of the following interventions in the plan?