A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

Hypoxemia due to dead space

Impaired carbon dioxide elimination due to shunting

Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch

Decreased pulmonary compliance due to stiffness

Answer and Explanation

The Correct Answer is D

Choice A Reason:

Hypoxemia due to dead space is not appropriate. Dead space refers to areas of the lung where ventilation occurs but no perfusion takes place. In ARDS, hypoxemia typically occurs due to ventilation-perfusion (V/Q) mismatch and shunting rather than dead space.

Choice B Reason:

Impaired carbon dioxide elimination due to shunting is not appropriate. Shunting occurs when blood bypasses ventilated alveoli, leading to inadequate gas exchange. In ARDS, shunting contributes to hypoxemia, but it doesn't directly impair carbon dioxide elimination.

Choice C Reason:

Decreased pulmonary arterial pressure due to ventilation-perfusion (V/Q) mismatch is incorrect. V/Q mismatch occurs when ventilation and perfusion are mismatched in different areas of the lung. This leads to areas of low ventilation (dead space) and areas of low perfusion (shunting). V/Q mismatch contributes to hypoxemia in ARDS but does not typically lead to decreased pulmonary arterial pressure.

Choice D Reason:

Decreased pulmonary compliance due to stiffness is correct. This is a characteristic feature of ARDS. The inflammation and damage to the alveoli cause them to become stiff, reducing pulmonary compliance and impairing lung expansion during ventilation.

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Correct Answer is D

Explanation

Choice A Reason:

Hypertension is not typically associated with heterotopic ossifications. However, it may occur in individuals with spinal cord injuries (SCI) due to autonomic dysreflexia, a condition characterized by an exaggerated sympathetic response to stimuli below the level of injury. Autonomic dysreflexia can lead to a sudden increase in blood pressure, which, if left untreated, can result in complications such as stroke or seizure. However, hypertension is not directly related to heterotopic ossifications.

Choice B Reason:

Bradycardia is also not typically associated with heterotopic ossifications. Like hypertension, bradycardia may occur in individuals with SCI due to autonomic dysreflexia. Autonomic dysreflexia can lead to a sudden increase in blood pressure and a reflex bradycardia in response to the increased sympathetic outflow. However, bradycardia is not directly related to heterotopic ossifications.

Choice C Reason:

Fecal impaction is a potential complication of spinal cord injury (SCI) due to impaired bowel function, but it is not directly related to heterotopic ossifications. SCI can disrupt normal bowel motility and result in neurogenic bowel dysfunction, leading to symptoms such as constipation, fecal impaction, and bowel obstruction. However, fecal impaction is not specific to heterotopic ossifications.

Choice D Reason:

Arthralgia is correct. Heterotopic ossifications (HO) involve the abnormal formation of bone in soft tissues around joints, muscles, tendons, or ligaments. When HO occurs around joints, it can lead to symptoms such as pain, swelling, and decreased range of motion, collectively known as arthralgia. Therefore, arthralgia is a common finding associated with heterotopic ossifications in individuals with spinal cord injuries.

A. "Are you having any feelings of depression?" B. "Are you experiencing any sensitivity to light?" C. "Are you feeling any increase in your sexual drive?" D. "Are you experiencing any episodes of 'panic-type' feelings?" E. "Are you experiencing more fatigue as compared to before you had migraines?"

Correct Answer is ["A","D","E"]

Explanation

Choice A Reason:

"Are you having any feelings of depression?". This statement is appropriate. Migraines can significantly impact mood, and depression is a common comorbidity in individuals with chronic migraines. Inquiring about feelings of depression allows the nurse to assess the client's mental health status and provide appropriate support or referrals if needed.

Choice B Reason:

"Are you experiencing any sensitivity to light?": This statement is inappropriate. This question addresses a physical symptom commonly associated with migraines rather than psychosocial impact.

Choice C Reason:

"Are you feeling any increase in your sexual drive?"Migraines are more likely to decrease sexual drive due to pain and fatigue. This question is not typically relevant to the psychosocial impact of migraines.

Choice D Reason:

"Are you experiencing any episodes of 'panic-type' feelings?" This statement is appropriate. Migraines can sometimes trigger anxiety or panic attacks in affected individuals. Inquiring about panic-type feelings allows the nurse to assess the client's emotional response to migraines and provide interventions or referrals for anxiety management if necessary.

Choice E Reason:

"Are you experiencing more fatigue as compared to before you had migraines?": This statement is appropriate. Fatigue is a common symptom associated with migraines, both during and after an attack. Assessing the client's level of fatigue helps the nurse understand the impact of migraines on the client's energy levels and overall functioning.

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A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a spinal cord injury with heterotopic ossifications. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who reports continuing problems related to migraines. The nurse is assessing the psychosocial impact of migraines on the client. Which of the following questions should the nurse include in the assessment? (Select All that Apply.)

Correct Answer is ["A","D","E"]

Explanation

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A nurse is teaching a client who has a complete spinal cord injury about bowel and bladder management. Which of the following instructions should the nurse include in the teaching? (Select all that apply.) (Select All that Apply.)

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