A nurse is assisting with the care of a client.
Vital Signs.
1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.
Respiratory rate 16/min.
Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.
Temperature 37 °C (98.6 °F) Heart rate 112/min.
Respiratory rate 20/min.
Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.
Temperature 38.3 °C (101 °F) Heart rate 152/min.
For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
Each finding may support more than 1 disease process.
Wheezes
Muscle rigidity
Urticaria
Hypercapnia
Tachycardia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B,C"}}
Wheezes: This finding may indicate a latex allergy, as wheezing is a sign of respiratory distress caused by an allergic reaction to latex proteins. Wheezes are not typical of malignant hyperthermia or hypovolemic shock.
Muscle rigidity: This finding is a hallmark of malignant hyperthermia, as it reflects the excessive calcium release and muscle contraction triggered by certain anesthetic agents. Muscle rigidity is not a feature of latex allergy or hypovolemic shock.
Urticaria: This finding is a common manifestation of latex allergy, as urticaria (hives) is a type of skin rash caused by an allergic reaction to latex proteins. Urticaria is not associated with malignant hyperthermia or hypovolemic shock.
Hypercapnia: This finding is indicative of malignant hyperthermia, as hypercapnia (high carbon dioxide levels in the blood) is a result of increased metabolism and oxygen consumption due to muscle rigidity and fever. Hypercapnia is not usually seen in latex allergy or hypovolemic shock, unless there is severe respiratory compromise.
Tachycardia: This finding can be present in all three disease processes, as tachycardia (fast heart rate) is a nonspecific response to stress, fever, pain, hypoxia, or hypovolemia. However, tachycardia is more pronounced and persistent in malignant hyperthermia and hypovolemic shock than in latex allergy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Peer-reviewed journal articles undergo a rigorous review process by experts in the field before being published. This process ensures that the information presented is based on sound research methods, accurate data, and relevant evidence. Journal articles are considered reliable sources of information as they are reviewed by experts in the field, and the research findings can contribute to evidence-based practice.
First-hand experience with wound care products: While personal experience can be valuable, it may not always reflect the most up-to-date or evidence-based practices. Individual experiences can be subjective and may not have been subject to rigorous evaluation or research.
Information from a wound care product vendor: Information from a vendor may be biased and focused on promoting their own products. It is important to critically evaluate the information and consider whether it is supported by evidence and aligns with current best practices.
An entry on a nursing blog addressing wound healing: Blog entries can vary in quality and credibility. Not all blogs are written or reviewed by experts, and the information provided may not always be evidence-based or reliable. It is important to critically assess the source, author's qualifications, and references cited in the blog post.
Correct Answer is B
Explanation
Choice A rationale:
Limiting the use of familiar objects is not recommended for clients with Alzheimer's disease. Familiar objects can provide comfort and security to these clients and help them maintain a sense of familiarity in their environment.
Choice B rationale:
Making a schedule of daily tasks is a helpful intervention for clients with Alzheimer's disease. Routine and structure can reduce frustration and anxiety in clients with cognitive impairment by providing predictability and a sense of purpose.
Choice C rationale:
Having several family members visit daily may be overwhelming for the client with Alzheimer's disease, leading to increased confusion and agitation. It is essential to balance social interaction with the client's comfort level and needs.
Choice D rationale:
Asking questions that require more than one answer can be confusing for clients with Alzheimer's disease. s should be simple and straightforward to enhance understanding and communication.
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