A patient is recuperating in the critical care unit following a cardiac catheterization.
IV nitroglycerin and heparin are being administered.
The patient is sedated but responds to verbal instructions.
After changing positions, the patient reports pain at the right groin insertion site.
What action should the nurse take?

Choice A rationale

Discussing moving to Hawaii does not necessarily indicate a connection to the client’s current condition. It could be a long-term plan or a dream.

Choice B rationale

Being unemotional when talking about needing to rebuild their house could indicate a coping mechanism or emotional detachment. However, without additional context, it’s difficult to definitively associate this behavior with their current condition.

Choice C rationale

Expressing a desire to be in a quieter area of the unit could indicate that the client is experiencing stress, anxiety, or discomfort in their current environment. This behavior is most likely associated with their current condition as it shows a direct response to their surroundings.

Choice D rationale

Requesting sleeping medication for the night could indicate various issues such as insomnia, anxiety, or other sleep-related disorders. However, without more information about the client’s current condition, it’s not possible to make a direct association.

Choice A rationale

The patient’s history of asthma, previous hospitalizations for asthma-related symptoms, and the current presentation of difficulty breathing and wheezing suggest that she is likely experiencing an asthma exacerbation related to environmental factors. Asthma is a chronic condition that can cause symptoms such as wheezing, shortness of breath, and chest tightness, which the patient is currently experiencing. Environmental factors such as allergens, air pollution, and changes in weather can trigger asthma symptoms.

Choice B rationale

While smoking is a major risk factor for COPD, the patient denies smoking. Additionally, COPD is more common in older adults, and the patient is only 22 years old. Therefore, it is less likely that her symptoms are due to COPD.

Choice C rationale

Pneumonia is typically associated with additional symptoms such as fever, cough with phlegm, and chest pain. The patient’s symptoms do not align with a typical presentation of pneumonia.

Choice D rationale

Tuberculosis is a bacterial infection that typically presents with a chronic cough, weight loss, and night sweats. The patient’s symptoms do not align with a typical presentation of tuberculosis.