A nurse is caring for a client who has respiratory failure due to ventilation-perfusion (V/Q) mismatch. The nurse should recognize that the client most likely has which of the following conditions?
Flail chest
Emphysema
Congestive heart failure
Guillain-Barré syndrome
The Correct Answer is B
Choice A Reason:
Flail chest is incorrect. Flail chest is a condition characterized by multiple rib fractures, causing instability in the chest wall. While it can lead to respiratory distress, it doesn't directly cause ventilation-perfusion (V/Q) mismatch. Instead, it impairs the mechanics of breathing by compromising chest wall integrity.
Choice B Reason:
Emphysema is a chronic obstructive pulmonary disease (COPD) where the alveolar walls are destroyed, leading to a loss of surface area for gas exchange. This results in areas of the lungs that are well-perfused but poorly ventilated, causing a V/Q mismatch. The damage to alveoli leads to impaired ventilation, while blood flow may still be adequate, leading to hypoxemia (low oxygen levels in the blood).
Choice C Reason:
CHF primarily affects the heart’s ability to pump blood effectively, leading to pulmonary congestion and impaired gas exchange. However, it typically causes diffusion defects rather than a direct ventilation-perfusion mismatch. V/Q mismatch may occur secondary to pulmonary edema, but it’s not the primary mechanism of respiratory failure in CHF.
Choice D Reason:
Guillain-Barré syndrome is incorrect. Guillain-Barré syndrome (GBS) is a neurological disorder that affects the peripheral nervous system, leading to muscle weakness and paralysis. While respiratory muscle weakness can occur in GBS, it doesn't directly cause ventilation-perfusion (V/Q) mismatch. GBS primarily affects nerve function rather than lung function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A Reason:
Photosensitivity is incorrect. Photosensitivity, or sensitivity to light, is not a common symptom of multiple sclerosis. While individuals with MS may experience visual disturbances, such as blurred vision or optic neuritis, sensitivity to light is not typically reported as a primary symptom.
Choice B Reason:
Memory issues is correct. Memory issues, including problems with short-term memory, concentration, and cognitive processing speed, are common neurological symptoms in individuals with multiple sclerosis. Cognitive impairment can affect various aspects of memory and cognitive function.
Choice C Reason:
Lhermitte's sign is correct. Lhermitte's sign is a classic neurological sign characterized by an electric shock-like sensation that radiates down the spine or into the limbs upon flexing the neck. It is a common symptom in multiple sclerosis, often associated with cervical spinal cord lesions.
Choice D Reason:
Seizures is incorrect. Seizures are not a typical symptom of multiple sclerosis. While individuals with MS may experience various neurological symptoms, seizures are not a common manifestation of the disease.
Choice E Reason:
Central vision loss is correct. Visual disturbances, including central vision loss, blurred vision, double vision, or optic neuritis, are common symptoms of multiple sclerosis. Optic neuritis, inflammation of the optic nerve, is a frequent manifestation of MS that can lead to temporary or permanent central vision loss.
Correct Answer is A
Explanation
Choice A Reason:
Decreased blood pressure is correct. Decreased blood pressure (hypotension) is the priority finding to monitor for because it is indicative of a severe allergic reaction known as anaphylaxis. Anaphylaxis is a potentially life-threatening condition that can lead to shock, organ failure, and death if not promptly treated. Hypotension in the context of an allergic reaction suggests widespread vasodilation and increased vascular permeability, resulting in a decrease in blood pressure.
Choice B Reason:
Stomach pain is incorrect. Stomach pain may indicate gastrointestinal distress or adverse effects of the antibiotic, but it is not typically as immediately life-threatening as decreased blood pressure in the context of anaphylaxis. While abdominal pain should not be ignored, it is not the priority finding when assessing for signs of anaphylaxis.
Choice C Reason:
Urticaria is incorrect. Urticaria, also known as hives, is a common allergic reaction characterized by raised, itchy welts on the skin. While urticaria can be uncomfortable and distressing, it is not immediately life-threatening. However, urticaria may be a precursor to more severe allergic reactions, such as anaphylaxis, so it is still important to monitor closely.
Choice D Reason:
Lightheadedness is incorrect. Lightheadedness may occur as a result of hypotension in the context of anaphylaxis, but it is not as critical as directly monitoring blood pressure. Lightheadedness may also be caused by other factors, such as anxiety or dehydration, and may not always indicate a severe allergic reaction. While it is important to assess for lightheadedness and monitor the client's overall condition, it is not the priority finding compared to decreased blood pressure.
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