A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?
Drowsiness.
Jaundice.
Flushed pink cheeks.
Tachycardia.
The Correct Answer is D
Choice A rationale:
Drowsiness is not a typical finding associated with hypoxia. Hypoxia often leads to increased alertness and anxiety as the body tries to compensate for the lack of oxygen. Drowsiness might be seen in severe cases of hypoxia, but it's not a consistent finding.
Choice B rationale:
Jaundice is not directly related to hypoxia. Jaundice is usually caused by elevated bilirubin levels due to liver dysfunction or other underlying issues. It is not a primary manifestation of hypoxia.
Choice C rationale:
Flushed pink cheeks can be an indicator of increased blood flow to the skin, which might occur as the body tries to compensate for hypoxia. However, this finding is not as consistent or specific as tachycardia in cases of hypoxia.
Choice D rationale:
Tachycardia, or an abnormally rapid heart rate, is a common physiological response to hypoxia. The body attempts to deliver more oxygen to tissues by increasing the heart rate. This compensatory mechanism helps maintain tissue perfusion in the face of reduced oxygen levels.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
The nurse should avoid assessing the popliteal pulse bilaterally at the same time. The popliteal pulse is located behind the knee and is relatively deep. Applying pressure on both sides of the knee to assess this pulse simultaneously can obstruct blood flow to the lower extremities. This is a particularly important consideration for clients with compromised circulation, such as those with peripheral vascular disease. Assessing this pulse sequentially is a safer approach.
Choice A rationale:
Assessing the femoral pulse bilaterally at the same time is generally acceptable. The femoral pulse is located in the groin area, and assessing it bilaterally doesn't impede blood flow significantly.
Choice C rationale:
Assessing the brachial pulse bilaterally at the same time is generally acceptable. The brachial pulse is located in the upper arm, and simultaneous assessment is unlikely to cause circulatory compromise.
Choice D rationale:
Assessing the carotid pulse bilaterally at the same time is discouraged. The carotid arteries are located in the neck, and applying bilateral pressure here can lead to reduced blood flow to the brain, potentially causing syncope (fainting) or other adverse effects. It's safer to assess this pulse sequentially.
Correct Answer is D
Explanation
Choice A rationale:
The choice "Pigeon" is not the correct answer. Pigeon chest, also known as pectus carinatum, is a deformity of the chest characterized by a protrusion of the sternum and ribs. This condition is not associated with chronic bronchitis.
Choice B rationale:
The choice "Funnel" is not the correct answer. Funnel chest, or pectus excavatum, is a deformity where the sternum is sunken into the chest. It is not the expected chest shape in chronic bronchitis.
Choice C rationale:
The choice "Kyphotic" is not the correct answer. Kyphosis refers to an excessive outward curvature of the thoracic spine, leading to a rounded upper back appearance. This is not the typical chest shape seen in chronic bronchitis.
Choice D rationale:
The correct answer is "Barrel." Choice D is the correct answer. Chronic bronchitis is a type of chronic obstructive pulmonary disease (COPD) characterized by airway inflammation and narrowing. Over time, this can lead to air trapping in the lungs and an increase in the anteroposterior diameter of the chest. This results in a barrel-shaped chest appearance, where the chest appears rounded and the ribs are more horizontal. This adaptation allows for increased lung capacity to accommodate for the compromised airflow in patients with chronic bronchitis.
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