A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Nausea

Severe dyspnea

Headache

Decreased level of consciousness

Hypotension

Answer and Explanation

Correct Answer : B,C,D,E

Choice a) is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of discomfort in the stomach that may or may not lead to vomiting. Nausea can be caused by many other conditions, such as gastroenteritis, motion sickness, or pregnancy.

Choice b) is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective feeling of difficulty or discomfort in breathing. Severe dyspnea indicates that the client is not getting enough oxygen and may have low blood oxygen levels (hypoxemia) or high carbon dioxide levels (hypercapnia).

Choice c) is correct because headache is a common manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can be caused by high carbon dioxide levels (hypercapnia), which can affect the blood vessels and nerves in the brain.

Choice d) is correct because a decreased level of consciousness is a common manifestation of ARF. Level of consciousness is a measure of how alert and oriented a person is. A decreased level of consciousness can be caused by low blood oxygen levels (hypoxemia), high carbon dioxide levels (hypercapnia), or acid-base imbalance, which can aﬀect brain function and mental status.

Choice e) is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal. Hypotension can be caused by low blood oxygen levels (hypoxemia), which can impair heart function and reduce cardiac output.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because the client's best motor response is 5, which means he can localize pain, not follow commands.

Choice B Reason: This is incorrect because the client's eye opening response is 3, which means he opens his eyes to pain, not to speech.

Choice C Reason: This is correct because the client's GCS score is 13, which indicates a severe impairment of consciousness. The GCS is a tool used to assess the level of consciousness of a person who has a head injury. The GCS score ranges from 3 to 15, with lower scores indicating lower levels of consciousness. A GCS score of 8 or less indicates coma. The client's GCS score is 3 + 5 + 5 = 13, which is above the coma threshold, but still indicates a severe impairment of consciousness. The other choices are not consistent with the client's GCS score.

Choice D Reason: This is incorrect because the client's best verbal response is 5, which means he can orient himself to person, place, and time, not that he is unable to make vocal sounds.

A. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. B. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart. C. Troponin is a protein that helps transport oxygen throughout the body. D. Troponin is a lipid whose levels reﬂect the risk for coronary artery disease.

Correct Answer is B

Explanation

Choice a) is incorrect because troponin is not an enzyme, but a protein. Enzymes are molecules that speed up chemical reactions in the body. Troponin does not have this function.

Choice b) is correct because troponin is a protein that binds to calcium and regulates the contraction of heart muscle fibers. When the heart muscle is injured, such as in a myocardial infarction, troponin leaks into the bloodstream and can be detected by a blood test. The higher the level of troponin, the more severe the damage to the heart.

Choice c) is incorrect because troponin does not help transport oxygen throughout the body. That function is performed by hemoglobin, which is a protein found in red blood cells.

Choice d) is incorrect because troponin is not a lipid, but a protein. Lipids are fats that are used for energy storage and cell membrane formation. Troponin does not have these roles.

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A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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