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 C
Explanation
Choice A rationale
Hypocortisolism, also known as Addison’s disease, is characterized by insufficient production of cortisol by the adrenal glands. It does not typically cause goiter, which is an enlargement of the thyroid gland due to various causes such as iodine deficiency, autoimmune diseases, or nodules.
Choice B rationale
Hyperinsulinemia refers to an excess level of insulin in the blood, often associated with insulin resistance and type 2 diabetes. It is not related to the development of goiter.
Choice C rationale
Iodide deficiency is a common cause of goiter. The thyroid gland requires iodine to produce thyroid hormones. When there is a deficiency, the gland enlarges in an attempt to capture more iodine from the bloodstream.
Choice D rationale
Azotemia is an elevation of blood urea nitrogen (BUN) and serum creatinine levels, typically due to kidney dysfunction. It is not associated with the development of goiter.
Correct Answer is A
Explanation
Choice A rationale
It takes about 14 days to develop antibodies and immunity to the disease after vaccine administration. This is why the patient is asked to return in 2 to 3 weeks for an antibody titer. The immune system needs time to respond to the vaccine and produce detectable levels of antibodies.
Choice B rationale
The laboratory running out of blood specimen tubes is not a valid reason for delaying the antibody titer. This choice does not provide an accurate explanation for the patient.
Choice C rationale
It takes about 14 days to develop antibodies, not antigens, and immunity to the disease after vaccine administration. This choice contains incorrect information about the immune response.
Choice D rationale
After receiving the vaccine, the patient is not likely to transmit the communicable disease to the laboratory. This choice does not provide a valid reason for delaying the antibody titer.