Exhibits here

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia.

Answer and Explanation

The Correct Answer is []

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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Correct Answer is C

Explanation

A. Phobia.
A phobia is an irrational fear of a specific object, situation, or activity that leads to a desire to avoid it. The client's behavior is more characteristic of a compulsion rather than a phobia.

B. Obsession.
An obsession is an intrusive, unwanted thought, image, or urge that causes significant anxiety.
While the client's fear of contamination could be an obsession, the handwashing itself is a compulsion.

C. Compulsion.
This is the correct answer because a compulsion is a repetitive behavior or mental act that a person feels driven to perform in response to an obsession. The client's excessive handwashing ritual is a classic example of a compulsion.

D. Addiction.
Addiction involves a compulsive need for and use of a habit-forming substance or behavior, typically involving a sense of euphoria or pleasure, which is not applicable to the client's behavior.

A. Instruct client and family to reconsider end of life choices. B. Encourage family to visit frequently. C. Teach client how to use guided imagery. D. Encourage family to bring the client old photographs. E. Record the client's desire to live.

Correct Answer is ["B","C","D"]

Explanation

A. Instruct client and family to reconsider end of life choices.
This is not an appropriate intervention. In hospice care, the focus is on providing comfort and supporting the client’s and family’s current end-of-life choices rather than challenging them.

B. Encourage family to visit frequently.
Encouraging family visits can provide emotional support and comfort to the client, helping them cope with feelings related to death and dying.

C. Teach client how to use guided imagery.
Guided imagery can be a helpful technique for managing anxiety and emotional distress, offering the client a method to find peace and comfort.

D. Encourage family to bring the client old photographs.
Old photographs can help evoke positive memories and provide comfort, aiding the client in coping with feelings of death and dying.

E. Record the client's desire to live.
Recording the client's desires is important for documenting their wishes, but it is not an intervention that directly aids in coping with feelings related to death and dying.

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Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

An older adult with a terminal illness is receiving hospice care and is having difficulty coping with feelings related to death and dying. What intervention(s) should the nurse include in this client's plan of care? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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Exhibits here

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia.