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) The time between ventricular depolarization and repolarization (diastole):
This refers to the period between ventricular depolarization and repolarization, which is associated with the QT interval on the EKG, not the P wave. The P wave specifically relates to atrial depolarization, not the ventricular activity. Diastole refers to the relaxation phase of the heart cycle, and it’s not directly linked to the P wave, which represents atrial contraction.

B) Time taken for impulse to spread to the point immediately preceding ventricular contraction:

The P wave represents the depolarization (or contraction) of the atria, not the time taken for the impulse to spread to the ventricles. The time taken for the impulse to spread through the atria, across the AV node, and down to the ventricles is better represented by the PR interval, not the P wave itself.

C) Time taken for depolarization (contraction) of both ventricles (systole):
This describes the QRS complex, which represents the depolarization (contraction) of the ventricles during systole, not the P wave. The QRS complex shows the electrical activity of the ventricles as they contract, while the P wave relates to atrial depolarization, which occurs before ventricular contraction.

D) Passage of electrical impulse through the atrium causing atrial depolarization:
The P wave represents the passage of the electrical impulse through the atria, leading to atrial depolarization. Depolarization of the atria results in the contraction of the atria, pushing blood into the ventricles. The P wave is the first part of the cardiac cycle on the EKG and reflects the electrical activity that causes atrial contraction.

A. "Are you having any headaches?" B. "How has your appetite been?" C. "Does your urine look clear or cloudy? " D. "Are you having trouble with spasms?"

Correct Answer is D

Explanation

A. "Are you having any headaches?" : While headaches can be a side effect of medications, this question does not directly assess the effectiveness of baclofen. Baclofen is primarily used to reduce muscle spasms and improve muscle tone.

B. "How has your appetite been?": Changes in appetite can be related to many factors, including medication side effects, but this question does not address the primary purpose of baclofen, which is to manage muscle spasms.

C. "Does your urine look clear or cloudy?": The appearance of urine is not directly related to the effectiveness of baclofen. This question might be more relevant to assessing other conditions or medications that affect the urinary system.

D. "Are you having trouble with spasms?": Baclofen (Lioresal) is prescribed to manage and reduce muscle spasms in conditions like multiple sclerosis. Asking the client about their experience with muscle spasms directly assesses the effectiveness of the medication in managing their symptoms.

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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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Naxlex Comprehensive Predictor Exams

The patient asks the nurse what the P Wave indicates on an EKG strip. The nurse informs the patient that the P Wave represents:

Correct Answer is D

Explanation

A home health nurse is making a home visit to a client with multiple sclerosis. The nurse reviews the home medications taken by the client. Which question should the nurse ask to determine the effectiveness of the client's medication, baclofen (Lioresal)?

Correct Answer is D

Explanation

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