The nurse caring for a critically ill client would suspect the development of acute respiratory distress syndrome (ARDS) in which of the following situations? The client with:
severe left sided heart failure and resultant pulmonary edema.
acute renal failure associated with pyelonephritis.
a traumatic brain injury with accompanying spinal cord injury.
hypoxemia, refractory to oxygen therapy.
The Correct Answer is D
A) Severe left-sided heart failure and resultant pulmonary edema:
While pulmonary edema due to left-sided heart failure can lead to respiratory distress and hypoxemia, it is not characteristic of ARDS. ARDS is a form of non-cardiogenic pulmonary edema, meaning it is not caused by heart failure. In contrast, pulmonary edema from heart failure is typically related to increased pressure in the pulmonary circulation. Therefore, while this client is at risk for respiratory issues, the cause of their pulmonary edema is distinct from the pathology seen in ARDS.
B) Acute renal failure associated with pyelonephritis:
Acute renal failure from pyelonephritis can lead to various complications, including electrolyte imbalances and fluid overload, which may affect respiratory function. However, renal failure by itself is not a direct cause of ARDS. ARDS is typically associated with an inflammatory response to injury or infection in the lungs, not specifically renal issues. While it’s important to monitor for pulmonary complications in critically ill clients, this situation does not directly suggest ARDS.
C) A traumatic brain injury with accompanying spinal cord injury:
Traumatic brain injury (TBI) with spinal cord injury can lead to respiratory compromise, particularly due to neurological impairment affecting the respiratory muscles or the brain's ability to control breathing. However, ARDS is not the most direct consequence of these injuries. ARDS is primarily caused by acute lung injury from direct or indirect insults to the lungs, such as trauma, pneumonia, or sepsis. Although this combination of injuries may cause respiratory distress, it is not a typical cause of ARDS unless there is another underlying lung injury.
D) Hypoxemia, refractory to oxygen therapy:
This is the hallmark sign of ARDS. ARDS is characterized by the development of acute hypoxemia that is resistant to high levels of supplemental oxygen therapy. This refractory hypoxemia is due to widespread inflammation and damage to the alveolar-capillary membrane, leading to impaired gas exchange. In ARDS, the lungs become less compliant, and the ability to oxygenate blood is significantly reduced, even with mechanical ventilation and high levels of oxygen. Therefore, a critically ill client with hypoxemia that does not improve with oxygen therapy would raise suspicion for the development of ARDS.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.9"]
Explanation
Step-by-Step Solution:
Convert the toddler's weight from pounds to kilograms.
1 pound is =0.453592 kilograms.
So, 26 pounds = 26 x 0.453592 = 11.793592 kilograms.
Calculate the total daily dose of prednisolone.
The prescribed dose is 2 mg/kg/day.
The toddler weighs 11.793592 kg.
The total daily dose = 2 mg/kg/day x 11.793592 kg = 23.587184 mg/day.
Determine the dose per administration.
The total daily dose is divided into two equal doses (every 12 hours).
The dose per administration = 23.587184 mg/day / 2 = 11.793592 mg per dose.
Calculate the volume of prednisolone syrup to administer.
The available prednisolone syrup is 15 mg/5 ml.
We need to administer 11.793592 mg per dose.
To find the volume, we can set up a proportion:
15 mg / 5 ml = 11.793592 mg / x ml
Cross-multiplying:
15x = 5 x 11.793592
Solving for x:
x = (5 x 11.793592) / 15 = 3.931197 ml
Round the answer to the nearest tenth.
3.9 ml.
Correct Answer is C
Explanation
A) Arrange for social service consult for assistance with medication purchase:
While arranging for social service support can be beneficial in ensuring the client has access to necessary medications, this is not directly related to fall prevention at home. Falls in Parkinson's disease are more closely associated with mobility, balance, and environmental factors, which should be the focus of interventions aimed at reducing fall risk. Medication access is important but secondary to safety measures related to physical environment and mobility.
B) Have the client seen by a nursing assistant 3 times a week for hygiene:
While assistance with hygiene can certainly help support the client’s daily needs, the frequency of visits for hygiene care alone does not specifically address fall prevention. Falls are more directly linked to issues such as impaired balance, freezing episodes, and poor mobility—issues that should be addressed through environmental modifications and specific interventions aimed at improving safety during ambulation and transfers.
C) Ensure adequate lighting in areas where the client will ambulate:
Ensuring adequate lighting in areas where the client will ambulate is a critical intervention for fall prevention in individuals with Parkinson's disease. Parkinson's disease often causes balance and coordination problems, and inadequate lighting can increase the risk of tripping or falling, especially at night or in poorly lit areas. Proper lighting helps the client see obstacles and navigate their environment safely. This intervention directly addresses a key factor in fall risk and is an important part of the plan of care.
D) Refer the client to a nutritionist to address dietary measures:
Referral to a nutritionist can be helpful in managing some aspects of Parkinson's disease, particularly for addressing issues like constipation, weight management, or dysphagia. However, dietary measures do not have a direct impact on fall prevention. Fall prevention should focus more on mobility, strength, environmental safety, and managing the symptoms of Parkinson's disease that affect balance and movement.
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