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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Intense pruritus (itching) noted during the assessment of the moles: While intense itching can be associated with skin changes and should be monitored, it is not a definitive sign of malignancy. However, it can be an early indicator that warrants further investigation, especially if accompanied by other changes in the mole.

B. Purulent drainage coming out of the moles: Purulent drainage typically indicates an infection rather than malignancy. While infections are serious and require treatment, they are not usually linked to skin cancer. This finding should prompt further assessment and appropriate wound care.

C. A healed sore noted upon assessment: A healed sore generally indicates that the area has resolved and is not immediately concerning. However, a non-healing or recurrent sore could be a sign of skin cancer and would need further evaluation by a healthcare provider.

D. The mole is larger than 6mm: A mole larger than 6mm is a significant indicator for potential malignancy, as size is one of the criteria in the ABCDE rule (Asymmetry, Border, Color, Diameter, Evolving) used for identifying melanoma. Larger moles warrant further examination to rule out skin cancer.

A. "ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication." B. "The disease is progressive and will eventually lead to paralysis while maintaining cognitive function." C. "Before you lose cognitive function, you should consider creating an advanced directive." D. "Despite severe symptoms right now, most patients recover with treatment."

Correct Answer is B

Explanation

A) "ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication."
Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disease that results in the progressive loss of motor neurons, which leads to muscle weakness, atrophy, and paralysis. It is not caused by "excess chemicals in the brain," and there are currently no medications that can cure ALS or completely control its symptoms. Medications such as riluzole can slow the progression slightly, but they do not stop or reverse the disease.

B) "The disease is progressive and will eventually lead to paralysis while maintaining cognitive function."
ALS is indeed a progressive neurodegenerative disease that leads to the gradual loss of muscle function due to the death of motor neurons. Over time, the patient will experience muscle weakness, atrophy, and paralysis, while the cognitive function typically remains intact until the later stages of the disease, although some patients may develop frontotemporal dementia. it is essential for the patient to understand that the disease will progressively impair their physical abilities while leaving cognitive functions largely unaffected in most cases.

C) "Before you lose cognitive function, you should consider creating an advanced directive."
While it is important for individuals with ALS to plan for the future, this statement is not entirely accurate. Cognitive function in ALS is often preserved throughout most of the disease, although there is a subset of patients who may develop frontotemporal dementia. It would be more appropriate to discuss advanced directives early in the disease, but it is not guaranteed that cognitive function will be lost before physical decline.

D) "Despite severe symptoms right now, most patients recover with treatment."
ALS is a progressive disease with no cure, and it does not typically result in recovery. While certain treatments can help manage symptoms or slow the progression of the disease, recovery is not a realistic expectation. Most patients with ALS experience gradual worsening of symptoms and ultimately may require assistance with daily activities as the disease progresses.

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A nurse is assessing a client who has early symptoms of hypoxia. Which of the following findings should the nurse expect?

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Explanation

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