The nurse is planning the care of a client diagnosed with emphysema. The client is not currently reporting increased dyspnea, but the nurse has noted the client is anxious. Which nursing intervention(s) should be implemented?
Administer their inhaler medications and increase the oxygen.
Notify the physician and administer lorazepam.
Dim the lights and encourage the client to take a nap.
Sit with the client and provide comfort measures.
The Correct Answer is D
Choice A reason:
Administering inhaler medications and increasing oxygen may be necessary if the client is experiencing respiratory distress. However, since the client is not currently reporting increased dyspnea, this intervention is not immediately required. The focus should be on addressing the client’s anxiety.
Choice B reason:
Notifying the physician and administering lorazepam may be appropriate if the client’s anxiety is severe and not manageable through non-pharmacological means. However, it is generally best to try comfort measures and non-pharmacological interventions first.
Choice C reason:
Dimming the lights and encouraging the client to take a nap can help reduce anxiety, but it may not be the most effective initial intervention. Providing direct comfort and reassurance is often more beneficial in addressing immediate anxiety.
Choice D reason:
Sitting with the client and providing comfort measures is the most appropriate intervention. This approach helps to alleviate anxiety through direct support and reassurance. Techniques such as deep breathing exercises, talking calmly, and providing a comforting presence can significantly reduce anxiety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Telling the patient to “try to go as long as possible before you press the button” is not advisable. PCA devices are designed to allow patients to manage their pain effectively by administering medication as soon as they begin to feel discomfort. Delaying the use of the PCA can lead to uncontrolled pain, which can be more difficult to manage later.
Choice B reason:
“Instruct your family or visitors to press the button for you when you are sleeping” is incorrect and potentially dangerous. Only the patient should press the PCA button to ensure that they are receiving the medication when they actually need it. Allowing others to press the button can lead to overmedication and serious side effects.
Choice C reason:
“Push the button every 15 minutes whether you feel pain at that time or not” is also incorrect. PCA devices are intended to be used on an as-needed basis. Pressing the button at regular intervals without experiencing pain can result in unnecessary medication administration and potential overdose.
Choice D reason:
“Push the button when you begin to feel pain, instead of waiting until the pain becomes worse” is the correct instruction. This approach helps to manage pain more effectively by preventing it from becoming severe. Early intervention with pain management can lead to better overall outcomes and patient comfort.
Correct Answer is D
Explanation
Pursed-lip breathing is a technique used to help manage shortness of breath and improve ventilation. It involves breathing in through the nose and exhaling slowly through pursed lips, as if blowing out a candle. This method helps to keep the airways open longer, allowing more air to escape and reducing the work of breathing.
Choice A reason:
Exhale quickly and forcefully through the mouth is not the correct intervention for pursed-lip breathing. Exhaling quickly and forcefully can cause the airways to collapse, making it harder to breathe out all the air. This can lead to air trapping and increased shortness of breath, which is counterproductive for clients with respiratory issues.
Choice B reason:
Inhale sharply with a “huff” sound is also not correct for pursed-lip breathing. Huff coughing is a technique used to clear mucus from the airways, not to manage breathing patterns. Inhaling sharply can cause irritation and may not provide the controlled breathing needed for effective gas exchange.
Choice C reason:
Inhale deeply through pursed lips is incorrect. The correct technique for pursed-lip breathing involves inhaling through the nose, not through pursed lips. Inhaling through the nose helps to filter and humidify the air, making it easier on the lungs and airways.
Choice D reason:
Exhale slowly through pursed lips is the correct intervention. This technique helps to prolong exhalation, which reduces the respiratory rate and improves ventilation. By keeping the airways open longer, it helps to release trapped air and improve oxygenation. This method is particularly beneficial for clients with chronic obstructive pulmonary disease (COPD) and asthma, as it helps to reduce the work of breathing and improve overall respiratory function.
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