A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
Headache
Severe dyspnea
Nausea
Hypotension
Hypotension
Correct Answer : B,D,E
Choice A Reason: This choice is incorrect because headache is not a common manifestation of ARF. Headache may be caused by various factors such as dehydration, stress, sinusitis, or migraine, but it does not indicate ARF.
Choice B Reason: This choice is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a difficulty or discomfort in breathing that affects the oxygen delivery and carbon dioxide removal from the body. It may be caused by various factors such as lung disease, heart disease, anemia, or anxiety, but it indicates ARF when it is severe and persistent.
Choice C Reason: This choice is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of uneasiness or discomfort in the stomach that may precede vomiting. It may be caused by various factors such as food poisoning, motion sickness, medication side effects, or pregnancy, but it does not indicate ARF.
Choice D Reason: This choice is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal (less than 90/60 mm Hg). It may be caused by various factors such as dehydration, blood loss, sepsis, or shock, but it indicates ARF when it is due to reduced cardiac output or vasodilation from hypoxia.
Choice E Reason: This choice is correct because decreased level of consciousness is a common manifestation of ARF. Decreased level of consciousness is a condition in which the person has impaired awareness or responsiveness to stimuli. It may be caused by various factors such as brain injury, stroke, seizure, or drug overdose, but it indicates ARF when it is due to increased carbon dioxide levels (hypercapnia) or decreased oxygen levels (hypoxemia) in the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because the client is not in deep coma, as the Glasgow Coma Scale (GCS) score ranges from 3 to 15, with 3 being the lowest possible score and indicating deep coma or death.
Choice B Reason: This is correct because the client needs total nursing care, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only open his eyes to pain, make incomprehensible sounds, and have abnormal flexion to pain.
Choice C Reason: This is incorrect because the client is not alert and oriented, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may not be able to follow commands, answer questions, or recognize people or places.
Choice D Reason: This is incorrect because the client is not responding to verbal stimuli, as the GCS score of 6 indicates a severe brain injury and a very low level of consciousness. The client may only respond to painful stimuli, such as pinching or squeezing.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because the laboratory values are not within the expected reference range in a client who has DIC. DIC is a condition that causes abnormal activation of the clotting cascade, leading to widespread microthrombi formation and consumption of clotting factors and platelets. This results in bleeding complications and organ dysfunction.
Choice B Reason: This is correct because the laboratory values are prolonged in a client who has DIC. PT, aPTT, and INR are tests that measure the time it takes for blood to clot. PT measures the extrinsic pathway, aPTT measures the intrinsic pathway, and INR is a standardized ratio of PT. In DIC, these tests are prolonged because of the depletion of clotting factors and platelets.
Choice C Reason: This is incorrect because the laboratory values are not the same as the previous test values in a client who has DIC. DIC is an acute and dynamic condition that can change rapidly depending on the underlying cause and treatment. The laboratory values may fluctuate between normal, prolonged, or shortened depending on the balance between clotting and bleeding.
Choice D Reason: This is incorrect because the laboratory values are not decreased in a client who has DIC. Decreased laboratory values would indicate a shortened clotting time, which can occur in some cases of DIC when there is excessive clotting and thrombosis. However, this is not the typical finding in DIC, as most clients present with bleeding manifestations and prolonged clotting time.
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