A nurse is assisting with the care of a client.

Vital Signs.

1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.

Respiratory rate 16/min.

Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.

Temperature 37 °C (98.6 °F) Heart rate 112/min.

Respiratory rate 20/min.

Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.

Temperature 38.3 °C (101 °F) Heart rate 152/min.

For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.

Each finding may support more than 1 disease process.

Choice A rationale:

The appropriate response by the nurse in this situation is to consider the client's request and check with the charge nurse to see if it's possible to adjust the smoke breaks. This response demonstrates a willingness to listen to the client's request and explore the possibility of accommodating their needs within the unit's policies and routines. It does not immediately grant the request but shows respect for the client's concerns and attempts to find a compromise.

Choice B rationale:

Asking the client why they feel extra smoke breaks should be allowed is not the best response. It may come across as confrontational and defensive, which can escalate the situation. Clients with antisocial personality disorder may have difficulty adhering to rules, so it's essential to approach their requests with a collaborative and problem-solving attitude.

Choice C rationale:

Offering an extra smoke break in exchange for participation in group therapy is not an appropriate response. It can be seen as manipulating the client or using rewards to control their behavior. It's essential to maintain clear boundaries and not use rewards or punishments as a means of managing clients with personality disorders.

Choice D rationale:

Telling the client the smoking times on the unit are after each meal is not an appropriate response either. It doesn't address the client's request and simply restates the unit's policy. It's important to engage in a more therapeutic and client-centered approach when responding to requests from individuals with personality disorders.

Choice A rationale:

Tilt your head forward while inhaling is not an appropriate instruction for using an albuterol metered-dose inhaler (MDI) In fact, it is recommended to keep the head in a neutral position while using an MDI to ensure proper delivery of the medication to the lungs. Tilted head positions can lead to ineffective inhalation and may result in the medication being deposited in the mouth or throat rather than reaching the lungs. Therefore, choice A is not the correct answer.

Choice B rationale:

Exhale immediately after inhaling is not an accurate instruction for using an albuterol MDI. The correct sequence is to inhale slowly and deeply through the mouth while pressing down on the canister to release the medication, hold the breath for a few seconds (usually 10 seconds), and then exhale slowly. Exhaling immediately after inhaling would not allow the medication to reach the lower airways effectively. Therefore, choice B is not the correct answer.

Choice C rationale:

"Close your mouth around the mouthpiece" is an essential instruction for using an albuterol MDI correctly. It ensures that the medication