A nurse is caring for a client who has a pulmonary embolism. The nurse should identify that the release of inflammatory mediators leads to which of the following pathologic findings?
Decreased pulmonary vascular resistance
Hypercapnia
Hypoventilation
Respiratory alkalosis
The Correct Answer is D
Correct answer: D
Choice A Reason:
Decreased pulmonary vascular resistance is incorrect. Inflammatory mediators released in response to a pulmonary embolism can lead to vasoconstriction and increased pulmonary vascular resistance. This is part of the body's response to redirect blood flow away from the affected area of the lung and maintain adequate perfusion to other areas.
Choice B Reason:
Hypercapnia is incorrect. Hypercapnia refers to elevated levels of carbon dioxide (CO2) in the blood. Hypocapnia usually is present with embolism; hypercapnia, on the other hand, is rare.
Choice C Reason:
Hypoventilation is incorrect. Hypoventilation occurs when there is inadequate ventilation of the lungs relative to metabolic demands. In the context of a pulmonary embolism, hypoventilation can occur due to factors such as pain, respiratory muscle fatigue, or impaired gas exchange, all of which can be influenced by the release of inflammatory mediators.
Choice D Reason:
Respiratory alkalosis is correct. In response to the blockage and the resulting inflammation, the body often increases the respiratory rate as a compensatory mechanism to maintain adequate oxygen levels and remove carbon dioxide. Due to the increased breathing rate, there is excessive exhalation of carbon dioxide, leading to a decrease in the partial pressure of CO2 in the blood. This results in an increase in blood pH, causing respiratory alkalosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
COPD is a chronic lung condition characterized by airflow limitation that is not fully reversible. Individuals with COPD often have underlying structural lung changes, such as emphysematous bullae or blebs. These areas of weakened lung tissue are prone to rupture, leading to the development of pneumothorax. Additionally, the chronic inflammation and damage to the airways and lung parenchyma in COPD contribute to the development of pneumothorax.
Choice B Reason:
Sarcoidosis is incorrect. Sarcoidosis is a granulomatous disease that primarily affects the lungs and lymph nodes. While it can cause lung damage and lead to pneumothorax, it is less common than COPD as a comorbidity associated with SSP.
Choice C Reason:
Lung cancer is incorrect. Lung cancer can lead to pneumothorax, especially if the tumor erodes into the pleural space. However, SSP is more commonly associated with underlying lung diseases like COPD rather than lung cancer.
Choice D Reason:
Cystic fibrosis is incorrect. Cystic fibrosis is a genetic disorder characterized by abnormal mucus production and impaired clearance in various organs, including the lungs. While individuals with cystic fibrosis are at increased risk of pneumothorax due to underlying lung disease, SSP is less commonly seen in this population compared to COPD.
Correct Answer is ["A","B","D"]
Explanation
Choice A Reason:
Muscle strength is correct. Assessing muscle strength is essential to determine if there are any neurological deficits or weakness that could indicate a neurological condition or injury. Sudden falls can be indicative of various neurological issues, such as stroke or transient ischemic attack (TIA). Assessing muscle strength helps identify any motor impairments or weakness that could contribute to the fall.
Choice B Reason:
Facial symmetry is correct. Assessing facial symmetry is crucial to identify any signs of facial droop, which could indicate a neurological deficit such as a stroke or Bell's palsy. Facial asymmetry may suggest damage to the facial nerve or other neurological issues.
Choice C Reason:
Peripheral pulses is incorrect. While assessing peripheral pulses is important for evaluating circulation, it may not be the priority assessment in this scenario where the client has suddenly fallen and may be experiencing neurological symptoms. Neurological deficits, such as weakness or changes in facial symmetry, vision, or speech, are more indicative of acute neurological issues like stroke or transient ischemic attack (TIA), which require immediate attention and intervention. In emergency situations, prioritizing assessments related to potential life-threatening conditions such as neurological deficits takes precedence over assessing peripheral pulses.
Choice D Reason:
Vision changes is correct. Assessing for vision changes is important to identify any visual disturbances or deficits that could contribute to falls or indicate underlying neurological issues such as a stroke or transient ischemic attack (TIA). Visual disturbances may include blurriness, double vision, or loss of vision in one or both eyes.
Choice E Reason:
Aphasia is incorrect. Assessing for aphasia, which is the inability to understand or express speech, is essential to identify any language deficits that could indicate a neurological condition such as a stroke. Aphasia may present as difficulty speaking, understanding language, or both.
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