Exhibits
The nurse is implementing solutions to provide care.
Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse determines that the client's is still having an adverse reaction resulting in symptoms ofdropdown,dropdownanddropdown
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E","dropdown-group-3":"A"}
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Dyspnea: Dyspnea, or difficulty breathing, can be a symptom of an adverse reaction such as an allergic reaction, anaphylaxis, or cardiovascular issues. It indicates a severe reaction that affects the respiratory system and requires immediate attention.
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Nausea: Nausea is a common symptom of adverse reactions to medications or other substances. It can accompany other symptoms like dizziness or headache and indicates that the client is experiencing an ongoing negative reaction to a treatment or exposure.
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Headache: A headache can be a manifestation of various adverse reactions, including those related to medication or changes in blood pressure. It is a significant symptom that may indicate worsening of the client's condition or an ongoing adverse reaction that needs to be addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wearing gloves when interviewing the client. This behavior may make the client feel stigmatized or rejected, as it could imply that the nurse perceives them as contagious or untouchable.
B. Allowing the client to ventilate feelings. While this is important for emotional support, it does not directly address the psychosocial need for acceptance.
C. Encouraging the client to join a support group. This can help the client feel less isolated and gain support from others with similar experiences, but it is not as immediate or direct as personal interaction.
D. Shaking the client's hand during an introduction. This gesture of physical contact can significantly convey acceptance and normalcy, helping the client feel respected and accepted despite their condition.
Correct Answer is []
Explanation
Cardiovascular
- Capillary refill 4 seconds
- A prolonged capillary refill time indicates poor peripheral perfusion, which can be a sign of hypoxia. Hypoxia can lead to reduced oxygen delivery to the tissues, resulting in delayed capillary refill.
Respiratory
- Oxygen saturation 90% on room air
- An oxygen saturation level of 90% is below the normal range (95-100%) and indicates that the blood is not adequately oxygenated, which is a direct sign of hypoxia.
- Respiratory rate 28 breaths/minute
- An elevated respiratory rate (tachypnea) is a common compensatory mechanism in response to hypoxia. The body attempts to increase oxygen intake and carbon dioxide expulsion by breathing more rapidly.
Neurological
- Anxious
- Anxiety can be a symptom of hypoxia. When the brain and other vital organs do not receive enough oxygen, it can trigger a sense of anxiety and restlessness as part of the body's alarm system.
- Restless
- Restlessness is another common symptom of hypoxia. It occurs because the body is trying to compensate for the lack of oxygen, leading to increased agitation and an inability to remain
calm.
Rationales for the Incorrect Choices:
- Cardiovascular
- Heart rate 101 beats/minute: While an elevated heart rate can be a compensatory response to hypoxia, it alone does not directly indicate hypoxia.
- Blood pressure 145/89 mm Hg: Elevated blood pressure is not a direct indicator of hypoxia and can be influenced by various factors including anxiety and pain.
- Respiratory
- Productive cough: A productive cough suggests respiratory infection or inflammation but does not directly measure oxygenation status or indicate hypoxia.
- Neurological
- Awake and alert: Being awake and alert indicates normal mental status and does not suggest hypoxia. Hypoxia typically affects cognitive function, leading to confusion or decreased level of consciousness in more severe cases.
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