A client with a history of asthma and bronchitis arrives at the clinic with shortness of breath and a productive cough with thickened, tenacious mucus. The client reports difficulty walking up a flight of stairs without experiencing breathlessness. Which action is most important for the nurse to instruct the client about self-care?
Teach anxiety reduction methods for feelings of suffocation.
Increase the daily intake of oral fluids to liquefy secretions.
Call the clinic if undesirable side effects of medications occur.
Avoid crowded enclosed areas to reduce pathogen exposure.
The Correct Answer is B
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.
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Correct Answer is B
Explanation
Choice A rationale
Autoimmune response is not the correct type of immune reaction for a bee sting. Autoimmune responses involve the body’s immune system attacking its own tissues, which is not the case with bee stings.
Choice B rationale
IgE response hypersensitivity is the correct type of immune reaction for a bee sting. Bee stings can trigger an IgE-mediated hypersensitivity reaction, leading to symptoms such as rash, difficulty breathing, and low blood pressure. This type of reaction is also known as anaphylaxis.
Choice C rationale
Cell-mediated hypersensitivity is not the correct type of immune reaction for a bee sting. Cell-mediated hypersensitivity involves T cells and is typically associated with conditions like contact dermatitis, not bee stings.
Choice D rationale
Type II hypersensitivity is not the correct type of immune reaction for a bee sting. Type II hypersensitivity involves antibody-mediated destruction of cells, which is not the case with bee stings.
Correct Answer is C
Explanation
Choice A rationale
Palpating large joints for nodules is not the most effective technique for assessing early signs of rheumatoid arthritis (RA). Nodules typically appear in more advanced stages of RA and are not an early sign.
Choice B rationale
Observing the skin for lesions is not specific to RA. While skin lesions can be associated with other conditions, they are not a primary indicator of early RA1.
Choice C rationale
Observing the client’s fingers is crucial for detecting early signs of RA. Early RA often presents with swelling, tenderness, and stiffness in the small joints of the fingers.
Choice D rationale
Palpating the lymph nodes is not relevant for early RA assessment. Lymph node enlargement is not a typical early sign of RA1.