An adult male was diagnosed with stage IV lung cancer three weeks ago.

His wife approaches the nurse and asks how she will know that her husband's death is imminent because their two adult children want to be there when he dies.

Which is the best response by the nurse?

Choice A rationale:

Increasing the supplemental oxygen to 15 L/min via nasal cannula may seem like a logical step given the client’s low oxygen saturation. However, it’s important to note that oxygen therapy should be titrated carefully. Too much oxygen can lead to oxygen toxicity, which can cause cellular damage and worsen the client’s condition. Therefore, this is not the priority action.

Choice B rationale:

Notifying the health care provider of the client’s condition is the priority action. The client’s oxygen saturation is 88% on room air, which is below the normal range of 95% to 100%. This indicates that the client is not getting enough oxygen, which can lead to hypoxia and other serious complications. The health care provider needs to be informed immediately so that appropriate interventions can be initiated.

Choice C rationale:

Administering ibuprofen as ordered for fever is important, but it’s not the priority in this situation. While fever can indicate an infection, which could be contributing to the client’s low oxygen saturation, addressing the immediate issue of hypoxia is more critical.

Choice D rationale:

Obtaining a sputum culture from the client could provide valuable information about the type of bacteria causing the pneumonia and guide antibiotic therapy. However, this is not an immediate priority compared to addressing the client’s low oxygen saturation. In summary, while all these actions are important in caring for a client with pneumonia, the nurse must prioritize interventions based on their urgency and potential impact on the client’s health status. In this case, notifying the health care provider of the client’s condition is the most critical action.

Choice A rationale:

An altered level of consciousness is not a typical finding in Alzheimer's disease. This condition is characterized by cognitive decline and memory impairment, but consciousness itself is not directly affected.

Choice B rationale:

Rapid mood swings can occur in individuals with Alzheimer's disease due to the changes in brain structure and function. These mood swings are a common behavioral symptom. However, the more distinctive hallmark of Alzheimer's disease is the cognitive decline rather than mood swings.

Choice C rationale:

Excessive motor activity is not a prominent feature of Alzheimer's disease. Instead, individuals with Alzheimer's disease often experience a decline in motor skills and coordination as the disease progresses.

Choice D rationale:

Failure to recognize familiar objects is a common symptom of Alzheimer's disease. This is referred to as agnosia, where individuals may struggle to recognize familiar people, objects, or places. It results from the progressive damage to brain regions responsible for memory and sensory processing.