An older adult client is admitted to the intensive care unit with severe abdominal pain, abdominal distention, and absent bowel sounds. The client has a history of smoking 2 packs of cigarettes daily for 50 years and is currently restless and confused. Vital signs are: temperature 96° F (35.6° C), heart rate 122 beats/minute, respiratory rate 36 breaths/minute, mean arterial pressure (MAP) 64 mm Hg and central venous pressure (CVP) 7 mm Hg. Serum laboratory findings include: hemoglobin 6.5 g/dL (65 g/L), platelets 60,000/mm³ (60 × 10⁹/L), and white blood cell count (WBC) 3,000/mm ³ (3 x 10 ⁹/L).

Based on these findings, this client is at greatest risk for which pathophysiological condition?

Reference Ranges:

Platelets: [150,000 to 400,000/mm ³ (150 to 400 x 10⁹/L)]

Hemoglobin: [14 to 18 g/dL (140 to 180 g/L)]

White Blood Cell: [5000 to 10,000/mm3 (5 to 10 x 10⁹/L)]

Mean Arterial Pressure: [70 to 105 mm Hg]

Central Venous Pressure: [2 to 8 mm Hg]

Disseminated intravascular coagulation (DIC).

Multiple organ dysfunction syndrome (MODS).

Acquired immunodeficiency syndrome (AIDS).

Chronic obstructive pulmonary disease (COPD).

Answer and Explanation

The Correct Answer is B

Multiple organ dysfunction syndrome (MODS) is the progressive physiological failure of two or more separate organ systems in an acutely ill patient. It usually results from a maldistribution of circulatory volume and a systemic inflammatory response. In the presence of hypoperfusion, cells switch to anaerobic metabolism, leading to lactic acidosis and subsequent cellular death across the pulmonary, renal, and gastrointestinal systems.

Rationale:

A. Disseminated intravascular coagulation (DIC) is a complex consumptive coagulopathy characterized by simultaneous systemic clotting and hemorrhage. While this client’s low platelets and hemoglobin suggest a potential hematological crisis, DIC is typically a secondary complication rather than the overarching condition. The presence of multi-system failure involving the bowels and brain points toward a broader syndrome.

B. Multiple organ dysfunction syndrome (MODS) is the greatest risk based on the clinical data. The client shows neurological (confusion), gastrointestinal (absent bowel sounds), hematological (pancytopenia), and cardiovascular (MAP 64 mm Hg) failure. This concurrent dysfunction of multiple systems, paired with tachycardia and tachypnea, indicates that the body can no longer maintain homeostatic balance independently.

C. Acquired immunodeficiency syndrome (AIDS) is a chronic disease caused by the human immunodeficiency virus. While the client has a low white blood cell count of 3,000/mm3, this is likely due to septic exhaustion or bone marrow suppression from acute illness. There is no historical or clinical data in the stem to support a primary diagnosis of advanced HIV infection.

D. Chronic obstructive pulmonary disease (COPD) is a chronic obstructive airway condition often linked to long-term smoking. Although the client has a significant smoking history and a high respiratory rate, COPD does not explain the multi-system collapse and low MAP. The acute presentation of abdominal distention and hypoperfusion suggests a far more critical and systemic pathophysiological process.

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Correct Answer is []

Explanation

Brief introduction:

Respiratory failure in clients with underlying chronic obstructive pulmonary disease (COPD) or emphysema is a medical emergency that requires rapid assessment and intervention. When a client’s oxygen saturation drops significantly (75% on room air), they may develop acute encephalopathy due to cerebral hypoxia, leading to the sudden onset of confusion. Restoring oxygenation is the immediate priority to prevent further physiological deterioration and permanent organ damage.

Rationale for Correct Choices:

Obstructed airway: The client demonstrates severe hypoxia (SpO₂ 75% on room air), circumoral cyanosis, acute confusion, and removal/loss of the oxygen mask. Although he is breathing, his oxygenation is critically impaired, suggesting ineffective airway/oxygen delivery likely due to airway obstruction or failure of oxygen support in a COPD patient.
Replace the nonrebreather mask: The mask was found on the floor, meaning the client is not receiving prescribed high-flow oxygen. Immediate replacement is essential to restore oxygen delivery.
Use a manual bag valve mask (BVM) to provide breaths: The client is deteriorating neurologically (new confusion) with severe hypoxia. BVM ventilation provides immediate high-concentration oxygen and supports ventilation when nonrebreather therapy is ineffective or not being tolerated.
Level of consciousness: Mental status is a sensitive indicator of hypoxia. Improvement or further decline reflects effectiveness of oxygenation and ventilation.
Skin color: Cyanosis and pallor reflect oxygenation status. Improvement in color indicates improved tissue oxygen delivery.

Rationale for Incorrect Choices:

Hypoxia: Although the client is clearly hypoxic, hypoxia is a physiological state rather than the specific underlying problem choice. The question is asking for the most likely condition causing the deterioration, and among the provided options, obstructed airway best explains the sudden inability to maintain oxygenation with loss of the oxygen device.
Apnea: Apnea is the absence of breathing. This client has tachypnea (RR 29/min), so apnea is not consistent with the presentation.
Pulmonary edema: Pulmonary edema typically presents with crackles, pink frothy sputum, and severe fluid overload signs. These findings are not described, and the key issue here is loss of oxygen delivery with acute deterioration.
Increase the flow of oxygen to 12 L: Simply increasing flow is ineffective if the oxygen device is not properly applied or if ventilation is compromised. Airway and ventilation support take priority.
Perform oropharyngeal suction: There is no evidence of visible secretions, choking, or gurgling suggesting secretion obstruction. The priority is restoring oxygen delivery and ventilation, not suctioning.
Change the oxygen delivery method to nasal cannula: A nasal cannula provides significantly less oxygen than a nonrebreather mask and would worsen severe hypoxemia.
Pulse pressure: This reflects cardiovascular function and is not a reliable indicator of oxygenation or airway patency in this scenario.
Color and consistency of mucous: This is more relevant to infection or chronic respiratory assessment rather than acute life-threatening hypoxia.
Gag reflex: This is useful for aspiration risk or airway protection assessment but does not reflect immediate oxygenation status or response to treatment.

A. Perform neurological assessment prior to discharge. B. Assess for drainage on dressing covering cervical incision. C. Auscultate blood pressure every 15 minutes for one hour. D. Monitor for tracheal deviation and swelling at biopsy site.

Correct Answer is D

Explanation

Brief introduction:

Hodgkin’s disease is a lymphatic malignancy characterized by the presence of Reed-Sternberg cells within lymphoid tissue. Cervical lymph node biopsy involves surgical entry into the neck, a highly vascular region containing the tracheal airway and major vessels. Post-procedural complications such as localized hematoma formation can cause rapid extrinsic compression of the trachea, leading to sudden and catastrophic respiratory obstruction in the postoperative period.

Rationale:

A. Performing a neurological assessment is necessary for clients receiving general anesthesia or those with potential intracranial involvement. However, this biopsy was performed under local anesthesia, making systemic neurological depression highly unlikely. While the nurse should monitor for local nerve damage, this is not the priority evaluation for life-threatening complications.

B. Assessing for drainage on the dressing is a standard nursing intervention to detect incisional bleeding. While monitoring for external hemorrhage is important, internal bleeding in the neck is more dangerous as it leads to airway compression. Focusing only on the dressing might miss an expanding internal hematoma that does not manifest as external drainage.

C. Auscultating blood pressure every 15 minutes is a routine part of postoperative monitoring to detect hemodynamic instability or shock. However, for a minor procedure under local anesthesia, systemic cardiovascular collapse is less likely than a localized respiratory emergency. Airway assessments always take precedence over routine vital signs in the immediate recovery phase of neck surgery.

D. Monitoring for tracheal deviation and swelling is the most important intervention. These findings indicate a rapidly expanding hematoma that is physically shifting the airway, which can lead to imminent asphyxiation. The nurse must prioritize monitoring the anatomical alignment of the trachea to ensure the client maintains a patent airway and can ventilate effectively.

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Naxlex Comprehensive Predictor Exams

Patient Data Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

A client recently diagnosed with Hodgkin's disease undergoes biopsy of cervical lymph nodes under local anesthesia. Which intervention is most important to include in this client's plan of care?

Correct Answer is D

Explanation

While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?

The nurse is considering priorities for the client's care. Drag from Word Choices to complete the sentence. The nurse knows that the priority concepts for nursing care management of the newborn with a patent ductus arteriosus are to dropdownanddropdown

The nurse is conducting a Mini-Mental State Exam (MMSE) with an older adult client. Which instruction assesses for recall?

Patient Data Chart is reviewed. Which discharge education should the nurse provide the client? Select all that apply.

A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the client's therapeutic response to this medication, which assessment should the nurse obtain?

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?