A patient was diagnosed with Bell's Palsy.
Which intervention should the nurse include in the care of this patient?

Choice A rationale

Increasing oxygen flow without assessing the client's respiratory status first can be detrimental for a client with COPD. High oxygen concentrations can suppress the hypoxic drive, which is a primary stimulus for breathing in some COPD patients, potentially leading to hypoventilation and respiratory acidosis.

Choice B rationale

While coughing and expectorating secretions can improve airway clearance, it is not the initial priority when a client with COPD reports difficulty breathing. A comprehensive assessment is crucial to determine the underlying cause of dyspnea before implementing interventions that may not be appropriate.

Choice C rationale

Calling emergency services immediately without first assessing the client's respiratory status is premature. The nurse needs to gather more information to determine the severity of the client's condition and whether immediate emergency intervention is warranted, or if other actions can alleviate the distress.

Choice D rationale

Assessing the client's respiratory status is the priority action. This involves evaluating respiratory rate, depth, effort, use of accessory muscles, oxygen saturation (SpO2), and breath sounds. This provides objective data to guide further interventions and determine the severity of the respiratory distress.

Choice A rationale

A ventricular pacemaker is designed to pace the ventricles, not the atria. Therefore, a pacemaker spike appearing before each P wave would indicate atrial pacing, which is not the primary function of a ventricular pacemaker. P waves represent atrial depolarization, and a ventricular pacemaker's stimulus is delivered to the ventricles to initiate a QRS complex.

Choice B rationale

A pacemaker spike appearing after each QRS complex suggests either oversensing, undersensing with competitive rhythms, or a malfunction. The purpose of a pacemaker spike is to *initiate* depolarization, not to follow it. If the spike occurs after the QRS, it indicates that the ventricle has already depolarized, and the spike is not contributing to ventricular contraction.

Choice C rationale

A pacemaker spike appearing with each T wave would be inappropriate and potentially dangerous. The T wave represents ventricular repolarization, a vulnerable period during which an electrical stimulus can induce life-threatening arrhythmias like ventricular fibrillation (R-on-T phenomenon). Pacing should occur before ventricular depolarization, not during repolarization.

Choice D rationale

A ventricular pacemaker functions by delivering an electrical impulse to the ventricle when its intrinsic rate falls below a programmed threshold. This impulse, seen as a pacemaker spike on the ECG, should precede ventricular depolarization, thus initiating a QRS complex. This indicates that the pacemaker is effectively stimulating ventricular contraction at the appropriate time.