nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
Hypotension
Decreased level of consciousness
Severe dyspnea
Headache
Nausea
Correct Answer : B,C
Choice A reason: Hypotension is not a common manifestation of ARF. Hypotension is a low blood pressure, defined as less than 90/60 mm Hg. Hypotension can have many causes, such as dehydration, blood loss, heart problems, or medications. ARF does not directly cause hypotension, but it can lead to complications such as shock or organ failure, which can lower the blood pressure.
Choice B reason: Decreased level of consciousness is a frequent manifestation of ARF. Decreased level of consciousness is a state of impaired awareness, orientation, memory, or judgment. Decreased level of consciousness can occur in ARF due to several factors, such as hypoxia, hypercapnia, acidosis, or infection. The nurse should monitor the mental status of the client with ARF and report any changes to the provider.
Choice C reason: Severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective sensation of difficulty breathing or shortness of breath. Severe dyspnea can occur in ARF due to the reduced oxygen delivery or increased carbon dioxide retention in the blood. The nurse should assess the respiratory rate, rhythm, depth, and effort of the client with ARF and provide oxygen therapy as prescribed.
Choice D reason: Headache is not a typical manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can have many causes, such as stress, dehydration, sinusitis, or migraine. ARF does not directly cause headache, but it can cause increased intracranial pressure or cerebral edema, which can trigger headache.
Choice E reason: Nausea is not a usual manifestation of ARF. Nausea is a feeling of sickness or discomfort in the stomach that can lead to vomiting. Nausea can have many causes, such as food poisoning, motion sickness, pregnancy, or medications. ARF does not directly cause nausea, but it can cause gastrointestinal bleeding or hepatic encephalopathy, which can induce nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect. Right hemiparesis is not a common finding in clients who had a stroke involving the right hemisphere. Hemiparesis is the weakness or partial paralysis of one side of the body. It usually affects the opposite side of the body from the side of the brain that is damaged by the stroke. Therefore, a stroke in the right hemisphere would more likely cause left hemiparesis, not right hemiparesis.
Choice B reason: This is incorrect. Aphasia is not a common finding in clients who had a stroke involving the right hemisphere. Aphasia is the loss or impairment of language functions, such as speaking, understanding, reading, or writing. It usually affects the dominant hemisphere of the brain, which is the left hemisphere for most people. Therefore, a stroke in the right hemisphere would less likely cause aphasia, unless the person is lefthanded or ambidextrous.
Choice C reason: This is correct. Inability to recognize his family members is a common finding in clients who had a stroke involving the right hemisphere. This is a type of agnosia, which is the loss or impairment of the ability to recognize objects, people, sounds, shapes, or smells. The right hemisphere of the brain is responsible for processing visual and spatial information, as well as facial recognition. A stroke in this area can damage the ability to identify familiar faces, even those of close relatives or friends.
Choice D reason: This is incorrect. Difficulty reading is not a common finding in clients who had a stroke involving the right hemisphere. Reading is a language function that involves the recognition and comprehension of written words. It usually depends on the dominant hemisphere of the brain, which is the left hemisphere for most people. Therefore, a stroke in the right hemisphere would less likely cause difficulty reading, unless the person is lefthanded or ambidextrous.
Correct Answer is B
Explanation
The correct answer is: b. Mold
Choice A: Radon
Radon is a radioactive gas that can cause lung cancer, but it is not specifically linked to asthma or allergies. While it is important to avoid radon for overall health, it is not a primary environmental trigger for asthma or allergies.
Choice B: Mold
Mold is a common allergen that can significantly worsen asthma and allergy symptoms. Mold spores can be inhaled, leading to respiratory issues, including asthma attacks and allergic reactions. Therefore, avoiding mold is crucial for individuals with asthma and allergies.
Choice C: Cockroaches
Cockroaches are known to be a significant trigger for asthma and allergies. Their droppings, saliva, and shed body parts can become airborne and exacerbate asthma and allergy symptoms. Avoiding cockroaches is important, but mold is typically a more direct and common trigger.
Choice D: Hepatitis B
Hepatitis B is a viral infection that affects the liver and is not related to asthma or allergies. It is important to avoid Hepatitis B for other health reasons, but it does not influence asthma or allergy symptoms.
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