A nurse is assessing a client who has hypoxemic respiratory failure. Which of the following findings should the nurse expect?

Pulmonary edema

Opioid toxicity

Myasthenia gravis

Flail chest

Answer and Explanation

The Correct Answer is A

A. Pulmonary edema: Pulmonary edema occurs when fluid accumulates in the lungs, impairing gas exchange and leading to hypoxemia. This condition is a common cause of hypoxemic respiratory failure, and patients often present with symptoms such as dyspnea, crackles on auscultation, and hypoxemia. The nurse would expect this finding in a client experiencing hypoxemic respiratory failure.
B. Opioid toxicity: Opioid toxicity can cause respiratory depression, but it typically leads to hypoventilation, which results in hypercapnic respiratory failure (elevated carbon dioxide levels) rather than hypoxemic respiratory failure. Therefore, while opioid toxicity affects breathing, it is not directly associated with hypoxemic respiratory failure.
C. Myasthenia gravis: Myasthenia gravis is a neuromuscular disorder that leads to muscle weakness, including respiratory muscles. While it can cause respiratory failure in severe cases, it does not directly cause hypoxemic respiratory failure. Respiratory failure in myasthenia gravis is often due to insufficient ventilation rather than impaired oxygenation, so this is not the expected finding in hypoxemic respiratory failure.
D. Flail chest: Flail chest occurs due to multiple rib fractures that result in a segment of the chest wall moving paradoxically, impairing ventilation. While this condition can lead to respiratory failure, it typically causes hypercapnic rather than hypoxemic respiratory failure. Therefore, it is less likely to be the cause of hypoxemic respiratory failure in this scenario.

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Correct Answer is C

Explanation

A. The client should maintain systolic BP between 141 and 145 mm Hg. This BP range is too high for clients with hypertension, especially those who have had a transient ischemic attack (TIA). The goal is to reduce BP to lower levels to prevent further stroke risk.
B. The client should maintain systolic BP between 136 and 140 mm Hg: This is still too high. Current guidelines recommend keeping systolic BP lower to reduce the risk of recurrent strokes or further vascular damage.
C. The client should maintain systolic BP between 120 and 129 mm Hg: This is the most appropriate target for clients with hypertension and TIA. Maintaining a BP within this range is known to reduce the risk of future strokes.
D. The client should maintain systolic BP between 130 and 135 mm Hg: While this range is lower than some others, it is still above the ideal target for stroke prevention, which is under 130 mm Hg for clients at high risk.

A. Decreased visual acuity B. Motor vehicle crashes C. Polypharmacy D. Weakness E. Chronic hypertension F. Previous military experience

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

Explanation

A. Decreased visual acuity: Decreased visual acuity is a significant factor in head injuries in older adults. Poor vision increases the likelihood of falls and accidents, as individuals are less able to detect obstacles or changes in their environment, leading to an increased risk of injury, including head trauma.
B. Motor vehicle crashes: While motor vehicle accidents can lead to head injuries, they are not as prevalent in older adults compared to other causes such as falls. Older adults are more likely to sustain head injuries from falls rather than from motor vehicle crashes, especially since they may not be as active in driving or are more cautious on the road.
C. Polypharmacy: Polypharmacy, or the use of multiple medications, is a common issue in older adults and can significantly contribute to the risk of falls and head injuries. Certain medications, such as sedatives, antihypertensives, and medications affecting balance or cognition, can increase the risk of dizziness, confusion, and falls, leading to head trauma.
D. Weakness: Muscle weakness, particularly in the lower extremities, is common in older adults and increases the risk of falls. Weakness can impair balance and coordination, making it harder for individuals to prevent falls or recover from them, resulting in head injuries.
E. Chronic hypertension: While chronic hypertension is a risk factor for cardiovascular events such as stroke, it is not a direct cause of head injuries in older adults. Hypertension may contribute to falls indirectly by affecting the ability to maintain balance due to related health complications, but it is not a primary cause of head injuries.
F. Previous military experience: Military experience is not a typical risk factor for head injuries in older adults. Although previous trauma or combat exposure could result in earlier injuries, it is not a common cause of head injuries in older adults compared to other factors like falls, medication use, or weakness.

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A nurse is assessing a client who has hypoxemic respiratory failure. Which of the following findings should the nurse expect?

Nursing Test Bank

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Explanation

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