A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?
Cyanosis
Hypotension
Bradycardia
Tachycardia
The Correct Answer is D
A) Cyanosis:
Cyanosis, which is a bluish discoloration of the skin and mucous membranes, typically occurs with severe hypoxia or oxygen deprivation, usually when oxygen saturation levels drop below 85%. Cyanosis is a late sign of hypoxia, not an early sign. In the early stages of hypoxia, the body attempts to compensate, and cyanosis does not typically appear until oxygen levels are significantly low.
B) Hypotension:
While hypotension can be a consequence of severe or prolonged hypoxia, it is generally a late sign. In the early stages of hypoxia, the body compensates through mechanisms such as tachycardia and vasoconstriction, so hypotension would not be expected at this stage. Hypotension in a hypoxic patient usually signals progression to severe respiratory or circulatory failure.
C) Bradycardia:
Bradycardia (slow heart rate) is not typically associated with early hypoxia. Instead, the body tries to compensate for reduced oxygen levels by increasing heart rate (tachycardia) in the early stages. Bradycardia can occur in more severe stages of hypoxia, particularly if the body begins to struggle with compensating or if the patient progresses to a more critical state. However, it is not an early sign of hypoxia.
D) Tachycardia:
Tachycardia (an elevated heart rate) is an early compensatory mechanism that the body employs when oxygen levels are insufficient. The heart increases its rate to pump more blood (and thus oxygen) to vital organs and tissues. Tachycardia is one of the earliest signs of hypoxia and occurs as the body attempts to compensate for the decreased oxygen levels in the bloodstream.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}
Explanation
Dysrhythmias |
Transcutaneous Pacing |
Defibrillation |
Synchronized cardioversion |
Unstable Supraventricular tachycardia |
✔️ |
||
Unstable Bradycardia |
✔️ |
||
Ventricular Fibrillation |
✔️ |
||
Ventricular tachycardia with NO pulse |
✔️ |
||
Unstable Atrial Flutter |
✔️ |
Unstable Supraventricular Tachycardia: Synchronized Cardioversion
Unstable Bradycardia: Transcutaneous Pacing
Ventricular Fibrillation: Defibrillation
Ventricular Tachycardia with No Pulse: Defibrillation
Unstable Atrial Flutter: Synchronized Cardioversion
Rationales:
Unstable Supraventricular Tachycardia – Synchronized Cardioversion:
Synchronized cardioversion delivers a timed electrical shock to the heart during the R wave, avoiding the vulnerable T wave, which minimizes the risk of inducing ventricular fibrillation. This intervention is preferred for unstable SVT unresponsive to medications, as it restores normal sinus rhythm effectively.
Unstable Bradycardia – Transcutaneous Pacing:
Transcutaneous pacing provides electrical impulses to stimulate the heart when intrinsic conduction is insufficient. It is the recommended treatment for symptomatic bradycardia that does not respond to medications, ensuring adequate cardiac output while awaiting more definitive treatment.
Ventricular Fibrillation – Defibrillation:
Defibrillation delivers an unsynchronized shock to depolarize the entire myocardium, allowing the heart to reset and resume an organized rhythm. It is the first-line intervention for ventricular fibrillation, as the chaotic electrical activity makes the heart incapable of pumping blood.
Ventricular Tachycardia with No Pulse – Defibrillation:
Pulseless ventricular tachycardia requires defibrillation, as the rhythm is life-threatening and the absence of a pulse indicates the heart is not effectively pumping. This unsynchronized shock interrupts the abnormal rhythm, allowing normal sinus rhythm to potentially resume.
Unstable Atrial Flutter – Synchronized Cardioversion:
Synchronized cardioversion is used for unstable atrial flutter to restore sinus rhythm by delivering a precisely timed electrical shock. It is effective when pharmacological measures have not worked or are inappropriate, especially in cases of hemodynamic instability.
Correct Answer is C
Explanation
A) Bradycardia:
Benztropine is an anticholinergic medication used to manage the symptoms of Parkinson's disease by blocking the action of acetylcholine. While anticholinergic medications can affect heart rate, bradycardia is not a common side effect of benztropine. In fact, benztropine may have the opposite effect, potentially causing tachycardia (increased heart rate).
B) Excess salivation:
Excessive salivation is typically a symptom of Parkinson's disease itself, due to difficulty swallowing, rather than a side effect of benztropine. In fact, benztropine, as an anticholinergic agent, generally reduces salivation (anticholinergic effect), so this side effect is unlikely to occur with benztropine therapy.
C) Urinary retention:
Benztropine, being an anticholinergic drug, can inhibit the action of acetylcholine at muscarinic receptors in the bladder, leading to urinary retention. This is a common and serious side effect of anticholinergic drugs like benztropine. Urinary retention can lead to discomfort, urinary tract infections (UTIs), and kidney problems if not addressed.
D) Diarrhea:
Benztropine is more likely to cause constipation rather than diarrhea due to its anticholinergic effects. Anticholinergic medications often slow down gastrointestinal motility, leading to constipation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.