A nurse is assessing a client who has respiratory failure. Which of the following manifestations should the nurse identify as indicative of severe hypercapnia?
Cyanosis
Arrhythmias
Asterixis
Tachycardia
The Correct Answer is C
A. Cyanosis: Cyanosis is a late sign of hypoxemia, not specifically hypercapnia. It indicates poor oxygenation of tissues but does not directly reflect elevated carbon dioxide levels in the blood.
B. Arrhythmias: Arrhythmias may occur in respiratory failure due to hypoxemia or acid-base disturbances. However, they are not the most specific indicator of severe hypercapnia and can result from a range of metabolic or cardiac causes.
C. Asterixis: Asterixis, or "flapping tremor," is a neurologic manifestation of severe hypercapnia and altered mental status. It results from elevated CO₂ levels affecting brain function and is often seen in CO₂ narcosis or advanced respiratory failure.
D. Tachycardia: Tachycardia is a common compensatory response to hypoxia or hypercapnia, but it is nonspecific. It can be seen in many conditions and is not a definitive sign of severe carbon dioxide retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. S–Situation: The situation includes immediate information about why the client is being transferred or receiving care, such as current symptoms, diagnosis, or presenting complaint. It does not include upcoming procedures or equipment needs.
B. R–Recommendations: Recommendations include what actions or interventions are needed next, such as upcoming tests, procedures, or equipment setup. Mentioning the need for a suction setup and an endoscopy reflects planning for ongoing care and falls under this category.
C. B–Background: Background refers to the client's medical history, diagnosis, and events leading up to the current situation. It gives context but does not include plans for future care.
D. A–Assessment: Assessment includes clinical findings, vital signs, laboratory results, and how the client is currently presenting. It focuses on objective and subjective data, not future recommendations or equipment planning.
Correct Answer is B
Explanation
A. Cerebral edema is caused by osmotic cerebral edema: Osmotic cerebral edema refers to edema caused by an imbalance in osmotic pressure, typically due to conditions like hyponatremia. It is not the primary mechanism for cerebral edema in meningitis.
B. Cerebral edema is caused by the by-products of the pathogen that causes the meningitis: In meningitis, the inflammation and increased vascular permeability due to the infection contribute to cerebral edema. The by-products of the pathogen, including toxins, cause blood-brain barrier disruption, leading to edema.
C. Cerebral edema is caused by cerebrospinal fluid flowing from the intraventricular space to the interstitial area of the brain: While CSF changes can contribute to brain swelling, the primary cause of cerebral edema in meningitis is the inflammatory response to infection rather than fluid shifts.
D. Cerebral edema is caused by whole body inflammation which affects the brain the most: While systemic inflammation can affect the brain, cerebral edema in meningitis is more directly caused by the local inflammatory response within the brain rather than whole-body inflammation.
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.