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

None

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

Choice A Reason:

"It will be necessary to take a stool softener to keep you from becoming constipated." This instruction is correct. Individuals with spinal cord injuries often experience bowel dysfunction, including constipation, due to decreased mobility and impaired bowel function. Stool softeners can help soften the stool and facilitate easier bowel movements, reducing the risk of constipation and associated complications such as fecal impaction.

Choice B Reason:

"Suprapubic catheterization might have to be done if you are unable to catheterize yourself." This instruction is correct. Suprapubic catheterization involves the insertion of a catheter through the abdominal wall directly into the bladder to drain urine. It may be necessary if the client is unable to perform intermittent catheterization independently or if other methods of bladder management are ineffective or contraindicated.

Choice C Reason:

"You will need to learn how to do self-intermittent catheterization to drain your bladder." This instruction is correct. Self-intermittent catheterization involves inserting a catheter into the bladder to drain urine at regular intervals. It is a commonly used method of bladder management for individuals with spinal cord injuries to prevent urinary retention and bladder distention.

Choice D Reason:

"Do not drink fluids excessively as this may cause diarrhea," is not typically included in bowel and bladder management instructions for individuals with spinal cord injuries. Hydration is important for overall health and may help prevent complications such as urinary tract infections, kidney stones, and constipation. Therefore, option D is not appropriate for inclusion in the teaching for a client with a complete spinal cord injury.

Choice E Reason:

"To achieve a bowel movement, daily digital stimulation will need to be done." This instruction is incorrect. Digital stimulation involves gently stimulating the rectum with a lubricated gloved finger to initiate a bowel movement. It can help individuals with spinal cord injuries who have neurogenic bowel dysfunction to stimulate bowel motility and facilitate bowel evacuation.

A. Muscle strength B. Facial symmetry C. Peripheral pulses D. Vision changes E. Aphasia

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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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?

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