The nurse is planning care for a client with a direct (sliding) hiatal hernia. Nursing actions should be planned to meet which goal?

Choice A rationale:

Hypothermia is a condition in which the body's core temperature falls below 95°F (35°C). It is not directly indicated by the client's vital signs as presented in the question.

Other factors that would more strongly suggest hypothermia include exposure to cold environments, immersion in cold water, or impaired thermoregulation due to conditions like hypothyroidism or alcohol intoxication.

Choice C rationale:

Hypotension is a condition in which blood pressure is abnormally low. It is also not directly indicated by the client's vital signs as presented in the question.

Hypertension, on the other hand, is a condition in which blood pressure is abnormally high.

The client's history of hypertension, and the fact that he takes enalapril (an antihypertensive medication), suggests that he may be more likely to experience hypertension than hypotension.

Choice D rationale:

Hypertension, as mentioned above, is a condition in which blood pressure is abnormally high.

While it's possible that the client is experiencing hypertension, the question specifically asks about the condition indicated by the client's vital signs.

Tachypnea, or rapid breathing, is a more direct indication of the client's respiratory distress, which is a common symptom of pneumonia.

Choice B rationale:

Tachypnea is the most likely condition indicated by the client's vital signs.

Tachypnea is often a sign of respiratory distress, which can be caused by a variety of conditions, including pneumonia. When a person has pneumonia, their lungs become inflamed and filled with fluid, making it difficult to breathe.

This can lead to rapid, shallow breathing, which is called tachypnea.

Other signs of respiratory distress that may be present in a client with pneumonia include: Coughing

Wheezing Chest pain

Feeling short of breath

Use of accessory muscles to breathe (e.g., muscles in the neck and chest) Nasal flaring

Cyanosis (a bluish tint to the skin)

Choice A rationale:

A regular rapid heartbeat (tachycardia) is a common side effect of albuterol, a bronchodilator that relaxes the muscles in the airways to improve breathing. It's often expected after repeated doses. While it warrants monitoring, it doesn't necessarily require immediate intervention unless it becomes significantly elevated or causes other symptoms.

Choice B rationale:

Increased anxiety can also accompany breathing difficulties and albuterol administration. It's crucial to address anxiety, but it's not the most urgent finding in this scenario. Calming techniques and reassurance can often help manage anxiety, while more severe cases might require additional interventions.

Choice C rationale:

Uncontrollable shaking (tremors) is a more serious side effect of albuterol, indicating excessive stimulation of the sympathetic nervous system. It can progress to serious complications like seizures or cardiac events. Immediate intervention is crucial to prevent these risks. Actions might include:

Holding the next albuterol dose Notifying the healthcare provider Monitoring vital signs closely

Administering medications to counteract the tremors, such as beta-blockers, if ordered

Choice D rationale:

Throat irritation is a possible side effect of albuterol, but it's generally mild and self-limiting. It doesn't typically warrant immediate intervention in the absence of other concerning symptoms.