A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? Select all that apply

Sub-sternal chest pressure

02 sats at 75% on 100% Fi02

Anxiety and restlessness

Increasing dyspnea

Pitting edema to ankles

Answer and Explanation

Correct Answer : B,C,D

A. Sub-sternal chest pressure: Sub-sternal chest pressure can be a sign of cardiac issues such as angina or myocardial infarction, not typically seen with ARDS. ARDS primarily involves respiratory symptoms such as severe hypoxemia and increasing dyspnea.

B. O2 sats at 75% on 100% Fi02: A significant decrease in oxygen saturation despite 100% oxygen administration is a hallmark sign of ARDS. This condition is characterized by severe, refractory hypoxemia, where the lungs are unable to provide adequate oxygen to the bloodstream even with high levels of oxygen.

C. Anxiety and restlessness: Anxiety and restlessness are common in ARDS due to hypoxia and respiratory distress. As the body struggles to get sufficient oxygen, the client may experience increased anxiety, restlessness, and discomfort, which are signs of worsening respiratory function.

D. Increasing dyspnea: Increasing dyspnea, or difficulty breathing, is a classic symptom of ARDS. As the condition progresses, the client’s ability to breathe becomes more labored due to inflammation and fluid buildup in the alveoli, leading to worsening oxygenation.

E. Pitting edema to ankles: Pitting edema to the ankles is more commonly associated with heart failure or fluid retention rather than ARDS. ARDS typically causes fluid buildup in the lungs rather than peripheral edema, which occurs in cases of circulatory problems.

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Correct Answer is C

Explanation

A. Amnesia: Amnesia can occur with traumatic brain injury but is not a specific indicator of increased ICP. Memory loss may result from the injury itself rather than a change in intracranial pressure.

B. Tachycardia: Tachycardia can occur in response to stress or pain but is not typically a primary sign of increased ICP. Increased ICP often results in bradycardia rather than tachycardia as the body's compensatory response.

C. Restlessness: Restlessness is a common early sign of increased ICP, as the brain becomes increasingly unable to maintain normal functions due to pressure. This agitation is often one of the first symptoms before more severe changes in consciousness or vital signs occur.

D. Hypotension: Hypotension is not a primary sign of increased ICP. Increased ICP often leads to hypertension as a compensatory mechanism to maintain cerebral perfusion pressure. Hypotension may occur later in severe cases but is not an early sign.

A. An initial loss of consciousness followed by a coherent period and a subsequent loss of consciousness B. Narrowing pulse pressure with tachycardia C. Drainage of clear fluid from the ears and nose D. Extensive swelling under the eyes

Correct Answer is A

Explanation

A. An initial loss of consciousness followed by a coherent period and a subsequent loss of consciousness: An epidural hematoma typically presents with a brief loss of consciousness, followed by a lucid period, then a second loss of consciousness. This pattern is a hallmark sign due to rapid pressure buildup from the blood.

B. Narrowing pulse pressure with tachycardia: Narrowing pulse pressure and tachycardia are not associated with an epidural hematoma. More commonly, widening pulse pressure and bradycardia (Cushing’s triad) are seen in severe cases of increased intracranial pressure.

C. Drainage of clear fluid from the ears and nose: Drainage of clear fluid from the ears and nose may suggest CSF leakage, typically due to a skull fracture. This is not specific to an epidural hematoma, which primarily involves bleeding between the dura and skull.

D. Extensive swelling under the eyes: "Raccoon eyes" can be seen with basal skull fractures, but it is not specific to epidural hematomas. The hallmark manifestation is the consciousness pattern described in option A.

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