Patient Data

Exhibits

The nurse comes into the room to replace the IV bag and notices the client's extremities are violently jerking. The client is not arousable, and the oxygen saturation is 59% on the monitor.

Complete the following sentence by choosing from the lists of options.

Based on the information collected, the client is likely experiencing
dropdown
related to
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Rationale for Correct Choices

Hypoxia: The client’s oxygen saturation has dropped dramatically to 59%, indicating inadequate oxygenation to tissues. Hypoxia can result from airway compromise, impaired breathing, or respiratory failure and is a life-threatening emergency requiring immediate intervention.
Tonic clonic seizure: The violent jerking of the extremities, combined with unresponsiveness, is characteristic of a tonic-clonic seizure. These seizures involve generalized muscle contractions and loss of consciousness, often compromising oxygenation and increasing the risk of hypoxia.

Rationale for Incorrect Choices

Stroke: Although stroke can cause neurological deficits, sudden violent jerking movements and profound hypoxia are not typical presentations of an acute stroke, especially with a normal head CT.
Cardiac arrest: Cardiac arrest presents with absence of pulse, apnea, and unresponsiveness. The client still has a heart rate of 58 bpm, so cardiac arrest has not occurred.
Absence seizure: Absence seizures involve brief lapses in awareness without violent motor activity. The tonic-clonic movements observed here are inconsistent with an absence seizure.
Akinetic seizure: Akinetic seizures involve a sudden loss of muscle tone and brief immobility, not violent jerking. The client’s symptoms do not align with this seizure type.
Decorticate posturing: Decorticate posturing is rigid flexion of the arms toward the chest with leg extension, typically due to brain injury. The generalized jerking observed is characteristic of a seizure, not posturing.

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Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Obtain a stat arterial blood gas (ABG): ABGs provide valuable information about oxygenation and ventilation, but drawing them does not relieve acute dyspnea immediately and delays essential interventions.

B. Encourage the client to use pursed lip breathing: This technique prolongs exhalation, prevents airway collapse, and promotes CO₂ elimination, providing immediate relief of dyspnea in COPD patients.

C. Lower the bed to a semi-Fowler's position: Semi-Fowler’s reduces lung expansion compared to high-Fowler’s, which is already optimal for promoting ventilation in severe dyspnea.

D. Increase the client's oxygen to 6 liters/minute: High-flow oxygen can reduce hypoxic drive in COPD patients, potentially worsening CO₂ retention and respiratory acidosis. It is not the safest immediate intervention.

A. Presence of bilateral femoral pulses. B. Altered posture and balance during ambulation. C. Appearance of the skin on the client's legs. D. Signs of old and new ecchymosis.

Correct Answer is C

Explanation

Rationale:
A. Presence of bilateral femoral pulses: Femoral pulses assess perfusion to the upper legs, not the lower extremities. Hair loss on the lower legs is more related to peripheral arterial circulation rather than proximal pulse presence.

B. Altered posture and balance during ambulation: Posture and gait changes are linked to neuropathy or musculoskeletal issues but do not directly explain reduced hair growth on the legs. They provide neurologic, not vascular, information.

C. Appearance of the skin on the client's legs: Examining skin color, temperature, and texture provides information about peripheral circulation. Shiny, thin skin or discoloration supports the finding of impaired arterial blood flow leading to hair loss.

D. Signs of old and new ecchymosis: Bruising reflects fragile capillaries or clotting abnormalities. It does not correlate with decreased hair growth, which is tied to chronic vascular insufficiency.

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Naxlex Comprehensive Predictor Exams

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high-Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

Correct Answer is B

Explanation

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

Correct Answer is C

Explanation

Patient Data Exhibits The nurse is reviewing the client's dietary choices for opportunities to promote better outcomes by limiting gout attacks. Select the 3 dietary choices that are not part of the recommended diet for a client with gout.

Patient Data Exhibits The nurse considers educational needs. Select which items the nurse should include in the discharge education for client with stable chronic obstructive pulmonary disease (COPD). Select all that apply.

A client receiving thyroid replacement therapy following a thyroidectomy is seen in the clinic for a 6 weeks postoperative check up. Which assessment is most important for the nurse to obtain?

Patient Data Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

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The nurse establishes a nursing problem, "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care (POC) for this client?