A nurse is assessing a client who has chronic emphysema. The client is receiving oxygen at 2 L/min via nasal cannula and is resting with the head of bed elevated to a 45° angle. Which of the following findings should the nurse identify as an early indication of hypoxia?
Decreased level of consciousness
Restlessness
Circumoral cyanosis
Seizures
The Correct Answer is B
A. Decreased level of consciousness: This is a late sign of hypoxia, indicating significant oxygen deprivation and possible brain involvement. Immediate intervention is required at this stage.
B. Restlessness: Restlessness is an early clinical manifestation of hypoxia. It reflects the body’s initial response to inadequate oxygenation, often presenting as anxiety, irritability, or agitation, and should prompt further assessment and intervention.
C. Circumoral cyanosis: Cyanosis around the mouth is a late sign of hypoxia, typically appearing after prolonged oxygen deprivation when oxygen saturation has significantly dropped.
D. Seizures: Seizures occur only in severe, prolonged hypoxia or hypoxemia affecting the central nervous system. This is a late and serious indicator of oxygen deprivation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Compulsive attention to details: This behavior is more characteristic of obsessive-compulsive personality disorder, not antisocial personality disorder. It reflects a need for order and control rather than disregard for others.
B. Avoids interacting with others: Social withdrawal is typical of avoidant personality disorder. Clients with antisocial personality disorder generally seek interactions they can exploit, rather than avoiding social contact.
C. Uses others for personal gain: Exploiting others for personal benefit is a hallmark of antisocial personality disorder. Clients often display deceitfulness, manipulativeness, and a lack of regard for the rights or feelings of others, consistent with this diagnosis.
D. Socially awkward in group situations: Social awkwardness may be seen in schizoid or schizotypal personality disorders. Clients with antisocial personality disorder usually engage socially in a confident or charming manner when it serves their goals, rather than showing awkwardness.
Correct Answer is C
Explanation
A. The client needs assistance with learning to eat with the opposite hand: This is an aspect of rehabilitation and occupational therapy, focusing on adaptive techniques for daily living. It is not within the social worker’s primary role, so this information should be directed to therapy services.
B. The client will require a wheelchair for use in the home: Equipment needs such as wheelchairs are usually coordinated through physical therapy or case management. While the social worker may assist with resources, the primary focus is on functional mobility, which is addressed by therapy services.
C. The client needs assistance with paying medical bills: Financial assistance, insurance navigation, and access to community resources are within the social worker’s scope of practice. Reporting this need ensures the client receives support for managing medical expenses and continuity of care at home.
D. The client will require a prescription for home therapy: Prescriptions for home health services fall under the provider’s and therapy team’s responsibilities. The social worker may support logistics, but the primary coordination of therapy prescriptions is not their role.
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