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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Impaired sense of humor is not a common finding for a client who had a stroke involving the left cerebral hemisphere. Impaired sense of humor is more likely to occur after a stroke involving the right cerebral hemisphere, which is responsible for processing humor, irony, and sarcasm.
Choice B reason: Poor judgment is not a typical finding for a client who had a stroke involving the left cerebral hemisphere. Poor judgment is more likely to occur after a stroke involving the frontal lobe, which is involved in executive functions, such as planning, reasoning, and decision making.
Choice C reason: Intellectual impairment is a possible finding for a client who had a stroke involving the left cerebral hemisphere. The left cerebral hemisphere is dominant for language and analytical thinking in most people. A stroke affecting this hemisphere can impair the ability to speak, read, write, calculate, and comprehend information.
Choice D reason: Loss of depth perception is not a frequent finding for a client who had a stroke involving the left cerebral hemisphere. Loss of depth perception is more likely to occur after a stroke involving the occipital lobe, which is involved in visual processing, or the parietal lobe, which is involved in spatial awareness.
Correct Answer is A
Explanation
The correct answer is A. Moderate.
Choice A: Moderate
A moderate traumatic brain injury (TBI) is characterized by a loss of consciousness (LOC) lasting between 30 minutes and 6 hours. In this scenario, the client lost consciousness for 45 minutes, which falls within this range. Moderate TBIs often result in more significant symptoms and may require more intensive medical intervention compared to mild TBIs.
Choice B: Severe
Severe TBIs are typically defined by a loss of consciousness lasting more than 6 hours. Since the client in this case was unconscious for only 45 minutes, this classification does not apply. Severe TBIs often involve extensive brain damage and can lead to long-term complications or disabilities.
Choice C: Mild
Mild TBIs, also known as concussions, are characterized by a loss of consciousness lasting less than 30 minutes. Given that the client was unconscious for 45 minutes, this classification is not appropriate. Mild TBIs usually result in temporary symptoms that resolve with minimal medical intervention.
Choice D: No traumatic brain injury
This option is incorrect because the client experienced a significant head injury with a loss of consciousness for 45 minutes. Such an event clearly indicates a traumatic brain injury, and it is essential to classify it correctly to ensure appropriate medical care.
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