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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Tachycardia: Elevated T3 and T4 levels with suppressed TSH indicate hyperthyroidism, which increases metabolic rate and sympathetic nervous system activity. This often results in tachycardia due to increased cardiac demand and heightened sensitivity to catecholamines.
B. Decreased body temperature: Hyperthyroidism typically causes increased heat production and heat intolerance. Clients often feel warm or overheated, not cold, so a drop in body temperature would be unexpected.
C. Slow respiratory rate: Increased metabolism usually raises oxygen demand, leading to a normal or increased respiratory rate. A slow respiratory rate is not characteristic of hyperthyroid states.
D. Hypotension: Hyperthyroidism often causes systolic hypertension due to increased cardiac output. While some clients may experience normal blood pressure, persistent hypotension is not a common finding.

A. Ability to target and destroy CD4 lymphocytes B. Conversion of the virus's RNA into DNA C. Having reverse transcriptase enzyme D. Containing only a single strand of genetic material

Correct Answer is A

Explanation

A. Ability to target and destroy CD4 lymphocytes: HIV targets and destroys CD4 lymphocytes, which are a key component of the immune system. This destruction weakens the immune system, making the individual more susceptible to opportunistic infections. This is a central feature of HIV's pathogenesis.
B. Conversion of the virus's RNA into DNA: The conversion of HIV's RNA into DNA occurs during replication, but this alone does not cause opportunistic infections. It is the destruction of CD4 cells that leads to the immune suppression and susceptibility to infections.
C. Having reverse transcriptase enzyme: Reverse transcriptase is an enzyme that helps HIV replicate its RNA into DNA. While essential for HIV replication, the presence of reverse transcriptase does not directly cause opportunistic infections; it is the result of the viral replication that weakens the immune system.
D. Containing only a single strand of genetic material: HIV contains single-stranded RNA as its genetic material. While this is true, the key factor in causing opportunistic infections is the virus’s ability to destroy CD4 cells, which weakens the immune system.

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A nurse is assessing a client who has respiratory failure. Which of the following manifestations should the nurse identify as indicative of severe hypercapnia?

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Naxlex Comprehensive Predictor Exams

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