A patient has been hospitalized after her house was destroyed in a hurricane.
She has spent two weeks in the intensive care unit and has now been transferred to the surgical floor for continued respiratory monitoring and completion of IV antibiotic therapy.
The patient reports a pain level of 2 on a scale of 0 to 10. She requests sleeping medication, explaining that she is haunted by distressing thoughts and memories of the house collapsing, which prevent her from sleeping.
She says, “I used to be so happy before all of this happened.
Now I can’t seem to get out of this funk I am in.”. She would also prefer a quieter area of the unit as she is currently near the nurses’ station and is disturbed by the noise.
After listening to the patient’s symptoms, the nurse suspects that she likely has:

Choice A rationale

While the frequency of a problem can provide some context, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency of a problem does not necessarily correlate with the quality or relevance of the evidence available.

Choice B rationale

Personal values are important in decision-making processes, but they are subjective and can vary greatly among individuals. Therefore, they are not the most important consideration when gathering objective, scientific evidence for evidence-based practice.

Choice C rationale

Relevance to the situation is the most important consideration when gathering evidence. Evidence must be directly applicable to the specific problem and context in order to be useful in informing decision-making. This includes considering the specific characteristics of the patient population, the nature of the problem, and the setting in which care is being provided.

Choice D rationale

Past experience with similar problems can provide valuable insights and context, but it is not the most important consideration. Past experiences are individual and subjective, and what worked in one situation may not work in another. Evidence-based practice requires the use of current, high-quality research evidence, which may or may not align with past experiences.

Choice A rationale

While auscultating breath sounds is an important part of assessing a client’s respiratory status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice B rationale

While measuring vital signs is an important part of assessing a client’s overall status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice C rationale

Assisting the client to a high Fowler’s position can help alleviate dyspnea by allowing for greater lung expansion. This should be the nurse’s first action when a client with ascites is dyspneic.

Choice D rationale

While deep breathing exercises can help improve lung function and may be beneficial for a client with ascites, they are not the first action the nurse should take when the client is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.