A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?
The client has a respiratory rate of 28 breaths per minute.
The client has a temperature of 38°C (100.4°F).
The client has a blood pressure of 140/90 mmHg.
The client has a heart rate of 90 beats per minute.
The Correct Answer is A
Choice A rationale
A respiratory rate of 28 breaths per minute indicates tachypnea, which is a sign of respiratory distress. Immediate intervention is needed to address the underlying cause and prevent further deterioration of the patient’s condition.
Choice B rationale
A temperature of 38°C (100.4°F) indicates a fever, which may suggest an infection. While this requires medical attention, it is not as immediately critical as respiratory distress.
Choice C rationale
A blood pressure of 140/90 mmHg is considered high, but it does not indicate an immediate need for intervention in the context of COPD. Hypertension should be managed, but it is not an acute emergency.
Choice D rationale
A heart rate of 90 beats per minute is within the normal range and does not indicate an immediate need for intervention. Monitoring the patient’s heart rate is important, but it is not an urgent concern in this scenario.
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Correct Answer is D
Explanation
Choice A rationale
Cerebral edema is the swelling of the brain due to fluid accumulation, which can occur after excessive alcohol consumption. However, it is not related to myxedema, which is a condition associated with severe hypothyroidism.
Choice B rationale
The deposit of fatty tissue is associated with conditions like hyperaldosteronism, where there is an excess production of aldosterone. This condition does not cause the characteristic skin changes seen in myxedema.
Choice C rationale
Proliferation of tissue behind the eyes, known as exophthalmos, is common in hyperthyroidism, particularly in Graves’ disease. Myxedema, on the other hand, is related to severe hypothyroidism and involves different pathophysiological mechanisms.
Choice D rationale
Myxedema is characterized by the accumulation of mucopolysaccharides in the skin and other tissues, leading to swelling and thickening of the skin. This condition is a result of severe hypothyroidism and can lead to a myxedema crisis if left untreated.
Correct Answer is C
Explanation
Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.