Which clinical manifestation is most reflective of an early response to hypoxia?
Restlessness
Cyanosis
Apnea
Bradycardia
The Correct Answer is A
Choice A Reason:
Restlessness is often one of the earliest signs of hypoxia. When the body experiences low oxygen levels, the brain is one of the first organs to be affected. This can lead to symptoms such as anxiety, agitation, and restlessness as the brain struggles to function properly without adequate oxygen. These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing respiratory and heart rates, which can make a person feel uneasy or restless.
Choice B Reason:
Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. While cyanosis is a significant indicator of hypoxia, it is typically a later sign. By the time cyanosis is visible, hypoxia has usually been present for some time, and oxygen levels have been critically low. Therefore, it is not the earliest clinical manifestation of hypoxia.
Choice C Reason:
Apnea is the absence of breathing. This is a severe and late sign of hypoxia. When a person stops breathing, it indicates that the body has been deprived of oxygen for an extended period, leading to critical conditions. Apnea is a medical emergency and requires immediate intervention, but it is not an early sign of hypoxia.
Choice D Reason:
Bradycardia is a slower than normal heart rate. Like apnea, bradycardia is a late sign of hypoxia. Initially, the body responds to low oxygen levels by increasing the heart rate (tachycardia) to pump more oxygenated blood to tissues. Bradycardia occurs when the body can no longer compensate, and the heart rate slows down, indicating severe hypoxia and impending failure of the cardiovascular system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Guided meditation and other nonpharmacological pain interventions can help reduce the perception of pain, which may allow for lower doses of pain management medications. This is beneficial as it can reduce the risk of side effects and dependency associated with higher doses of pain medications1. Studies have shown that integrating nonpharmacological methods like guided meditation can enhance overall pain management and improve the quality of life for patients2.
Choice B reason: Guided meditation is a complementary therapy and is not intended to replace pain medications entirely. While it can significantly aid in pain management, it is typically used alongside pharmacological treatments to provide a holistic approach to pain relief3. Relying solely on guided meditation without appropriate medical supervision and medication can lead to inadequate pain control.
Choice C reason: Guided meditation is not limited to hospital settings or licensed therapists. Many guided meditation resources are available online, through apps, or in community centers, making it accessible to a broader audience4. Patients can practice guided meditation at home, which provides flexibility and convenience in managing chronic pain.
Choice D reason: Pain medications are often prescribed on a regular schedule to maintain consistent pain control, especially in chronic pain conditions. While nonpharmacological interventions can reduce the need for frequent dosing, they do not eliminate the necessity for scheduled pain medications5. It is essential to follow a healthcare provider’s recommendations for medication administration to ensure effective pain management.
Correct Answer is C
Explanation
Choice A Reason:
The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.
Choice B Reason:
The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.
Choice C Reason:
The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.
Choice D Reason:
The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.
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