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 A
Explanation
A. Systemic lupus erythematosus: The butterfly-shaped rash, along with symptoms like fatigue, hair loss, and memory issues, is characteristic of systemic lupus erythematosus (SLE), an autoimmune disease. The rash typically appears across the cheeks and nose and is a hallmark sign of SLE, often triggered by sunlight exposure.
B. Acute HIV: Acute HIV infection may cause symptoms like fatigue, but it typically does not present with the specific butterfly-shaped rash seen in SLE. The rash associated with HIV is generally more generalized and not localized like the characteristic lupus rash.
C. Chronic HIV: Chronic HIV can present with fatigue and other symptoms, but it does not cause the butterfly-shaped rash seen in lupus. HIV-related rashes are more often generalized or occur due to secondary infections, not the distinct butterfly pattern seen in lupus.
D. Discoid lupus erythematosus: Discoid lupus erythematosus (DLE) can cause skin lesions, including facial rashes, but it does not present with the same systemic symptoms (like fatigue, hair loss, and memory issues) as systemic lupus erythematosus. DLE affects only the skin, whereas SLE affects multiple organs.
Correct Answer is A
Explanation
A. Insulin resistance: HHS typically occurs in clients with type 2 diabetes who have some circulating insulin, but not enough to prevent severe hyperglycemia. Insulin resistance is a key feature, as it allows glucose levels to rise without triggering significant fat breakdown or ketone production.
B. Metabolic acidosis: Metabolic acidosis is more commonly seen in diabetic ketoacidosis (DKA) due to the accumulation of ketones. In HHS, acidosis is usually absent or only mild because fat breakdown is minimal.
C. Hypervolemia: HHS leads to profound dehydration due to osmotic diuresis caused by severe hyperglycemia. Clients are more likely to be hypovolemic rather than hypervolemic due to fluid losses.
D. Ketosis: Unlike DKA, HHS generally does not present with significant ketosis because the body retains enough insulin to prevent fat breakdown. The absence of ketosis is one of the key diagnostic differences between the two conditions.
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.