A nurse is planning care for a patient who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea at rest. Which of the following interventions should be included in the plan of care?(Select all that apply.).

Positioning the patient in high Fowler's position.

Encouraging deep breathing and coughing exercises.

Administering bronchodilators and corticosteroids as ordered.

Providing supplemental oxygen via nasal cannula as ordered.

Restricting fluid intake to prevent fluid overload.

Answer and Explanation

Correct Answer : A,C,D

Choice A:

Positioning the patient in high Fowler's position. This is a correct intervention because it allows for optimal chest expansion and lung ventilation, reducing dyspnea and work of breathing.

Choice B:

Encouraging deep breathing and coughing exercises. This is an incorrect intervention because it may increase dyspnea and fatigue in a patient with COPD who already has difficulty breathing. Instead, the nurse should teach pursed-lip breathing and diaphragmatic breathing techniques to improve gas exchange and reduce air trapping.

Choice C:

Administering bronchodilators and corticosteroids as ordered. This is a correct intervention because these medications help to relax the smooth muscles of the airways, reduce inflammation, and improve airflow in a patient with COPD.

Choice D:

Providing supplemental oxygen via nasal cannula as ordered. This is a correct intervention because oxygen therapy helps to correct hypoxemia, reduce pulmonary hypertension, and improve exercise tolerance and quality of life in a patient with COPD. The nurse should monitor the oxygen saturation and adjust the flow rate according to the prescription and the patient's response.

Choice E:

Restricting fluid intake to prevent fluid overload. This is an incorrect intervention because fluid restriction is not indicated for a patient with COPD unless there is evidence of heart failure or renal impairment. Adequate hydration helps to thin the secretions and facilitate expectoration in a patient with COPD. The nurse should encourage oral fluids unless contraindicated and monitor the fluid balance and electrolytes of the patient.

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Correct Answer is A

Explanation

Choice A reason:

Asking the client when they first noticed the symptoms is a relevant and appropriate question for a problem-focused assessment. It helps the nurse to determine the onset, duration, and frequency of the nausea and vomiting, which can provide clues to the possible causes and severity of the problem.

Choice B reason:

Asking the client about allergies or food intolerances is not directly related to the problem of nausea and vomiting. It might be useful to ask this question later in the assessment, but it is not the priority at this point. This question is more suitable for a comprehensive or initial assessment.

Choice C reason:

Asking the client to rate their pain on a scale of 0 to 10 is not relevant to the problem of nausea and vomiting. Pain is a different symptom that might or might not be associated with nausea and vomiting. This question is more suitable for a pain assessment.

Choice D reason:

Asking the client about their health goals is not related to the problem of nausea and vomiting. This question is more suitable for a wellness assessment or a health promotion intervention.

A. The client's readiness and motivation to change. B. The availability and accessibility of CBT services. C. The cost and duration of CBT sessions. D. The compatibility and rapport between the client and therapist. E. The evidence base and efficacy of CBT for anxiety disorders

Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason:

The client's readiness and motivation to change are crucial factors for the success of CBT, as it requires active participation and homework assignments from the client. CBT is based on the premise that changing maladaptive thoughts and behaviors can improve emotional well-being. Therefore, the client needs to be willing and able to engage in this process and apply the learned skills to their daily life.

Choice B reason:

The availability and accessibility of CBT services are also important factors for the success of CBT, as they determine how often and how easily the client can receive the therapy. CBT is typically delivered in a time-limited and structured manner, with sessions ranging from 8 to 20 weeks. The client needs to have regular access to a qualified CBT therapist who can provide consistent and evidence-based treatment.

Choice C reason:

The cost and duration of CBT sessions are not relevant factors for the success of CBT, as they do not directly affect the quality or effectiveness of the therapy. CBT is generally considered to be a cost-effective and efficient intervention for anxiety disorders, as it can produce lasting benefits in a relatively short period of time. The cost and duration of CBT sessions may affect the client's preference or adherence to the therapy, but they are not essential for its outcome.

Choice D reason:

The compatibility and rapport between the client and therapist are vital factors for the success of CBT, as they influence the therapeutic alliance and the client's trust in the therapist. CBT is a collaborative and goal-oriented therapy that requires a strong working relationship between the client and therapist. The client needs to feel comfortable and supported by the therapist, who can provide empathy, feedback, guidance, and encouragement.

Choice E reason:

The evidence base and efficacy of CBT for anxiety disorders are significant factors for the success of CBT, as they demonstrate the validity and reliability of the therapy. CBT is one of the most researched and empirically supported psychological interventions for anxiety disorders, with numerous studies showing its superiority over other treatments or placebo. The client can benefit from knowing that CBT is based on sound scientific principles and proven techniques.

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A nurse is planning care for a patient who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea at rest. Which of the following interventions should be included in the plan of care?(Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting a problem-focused assessment for a client who reports nausea and vomiting. Which of the following statements should the nurse make to gather more information about the problem?

Correct Answer is A

Explanation

A nurse is identifying factors that contribute to success or failure of a plan of care for a client with anxiety disorder who is undergoing cognitive behavioral therapy (CBT). Which of the following factors should the nurse consider? (Select all that apply.).

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is documenting the data collected from a comprehensive physical exam of a client. Which of the following data should the nurse identify as objective data?

A nurse is performing an ongoing assessment for a client who has a pressure ulcer. Which of the following data should the nurse collect? (Select all that apply).

A nurse is evaluating a patient's response to pain medication after surgery. The patient reports that his pain level is 8 out of 10 on a numeric rating scale, despite receiving morphine 10 mg intravenously 30 minutes ago. What should the nurse do first?

A nurse is performing an emergency assessment for a client who is experiencing chest pain and shortness of breath. Which of the following questions should the nurse ask the client?

Which of these is an example of a goal rather than an outcome?

A nurse is documenting the data collected from an assessment of a client who has a urinary tract infection (UTI). Which of the following statements should the nurse use to record objective data?

A nurse is planning care for a patient who has chronic obstructive pulmonary disease (COPD) and is experiencing dyspnea at rest. Which of the following interventions should be included in the plan of care?(Select all that apply.).