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

Answer and Explanation

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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Correct Answer is D

Explanation

Choice A reason: Take isoniazid with an antacid. This answer is incorrect because taking isoniazid with an antacid can reduce the absorption and effectiveness of the drug. Isoniazid should be taken on an empty stomach, one hour before or two hours after meals.

Choice B reason: Drink at least 8 ounces of water when you take the pyrazinamide tablet. This answer is incorrect because drinking water with pyrazinamide is not necessary, as this drug does not cause dehydration or kidney problems. However, drinking plenty of fluids is generally recommended for clients with tuberculosis to prevent dehydration and help clear the lungs of secretions.

Choice C reason: Expect your sputum cultures to be negative after 6 months of therapy. This answer is incorrect because expecting sputum cultures to be negative after 6 months of therapy is unrealistic and misleading. The duration of treatment for tuberculosis varies depending on the type and extent of the infection, the drug regimen, and the client's response to the therapy. Some clients may need longer than 6 months to achieve negative sputum cultures.

Choice D reason: Provide a sputum specimen every 2 weeks to the clinic for testing. This answer is correct because providing sputum specimens regularly is important to monitor the effectiveness of the treatment and to determine when the client is no longer infectious.

A. Encourage brief exercise before meals to promote appetite. B. Encourage the client to take small bites. C. Place the client with the head reclined back to facilitate swallowing. D. Place food in the affected side of the mouth.

Correct Answer is B

Explanation

Choice A reason: Encourage brief exercise before meals to promote appetite. This answer is incorrect because exercise before meals can increase fatigue and decrease appetite in some clients with dysphagia. Exercise can also affect the blood flow to the brain and the muscles involved in swallowing .

Choice B reason: Encourage the client to take small bites. This answer is correct because taking small bites can help the client swallow more easily and reduce the risk of choking or aspiration.

Choice C reason: Place the client with the head reclined back to facilitate swallowing. This answer is incorrect because placing the client with the head reclined back can impair the swallowing mechanism and increase the risk of aspiration. The client should be placed with the head tilted slightly forward to help the food move down the throat.

Choice D reason: Place food in the affected side of the mouth. This answer is incorrect because placing food in the affected side of the mouth can cause the food to remain in the mouth and not be swallowed properly. The client should be encouraged to use both sides of the mouth to chew and swallow food.

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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.)

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