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
Decreasing speaking speed may help with clarity, but it does not address the issue of hearing loss.
Choice B rationale
Over-enunciating word syllables can help the client understand speech better, especially if they have hearing difficulties. This technique makes it easier for the client to read lips and understand spoken words.
Choice C rationale
Raising voice volume to a shout can be uncomfortable and may not improve understanding. It can also be perceived as rude or aggressive.
Choice D rationale
Exaggerating nonverbal expressions may help with communication, but it is not as effective as over-enunciating word syllables for clients with hearing difficulties.
Correct Answer is D
Explanation
Choice A rationale
Determining the neurological baseline prior to the fall is important but not the immediate priority. The client’s current confusion and projectile vomiting suggest a potential acute condition that needs immediate assessment.
Choice B rationale
Determining the client’s last dose of corticosteroids is relevant for managing multiple sclerosis but does not address the immediate concern of confusion and vomiting.
Choice C rationale
Administering a PRN IV antiemetic as prescribed can help manage vomiting but does not address the underlying cause of the symptoms.
Choice D rationale
Completing a head-to-toe neurological assessment is the priority intervention. The client’s confusion and projectile vomiting could indicate increased intracranial pressure or another acute neurological condition that requires immediate attention.