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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Muscle rigidity and bradykinesia: Parkinson's disease (PD) is characterized by a combination of motor symptoms due to the degeneration of dopamine-producing neurons in the brain. The hallmark motor symptoms include muscle rigidity (stiffness of muscles, making movement difficult) and bradykinesia (slowness of movement). These symptoms are typically present early in the disease and can lead to difficulties with daily activities such as walking, speaking, and performing fine motor tasks. These two signs are primary indicators of Parkinson's disease.

B. Facial pain and ptosis: Facial pain and ptosis (drooping eyelids) are not typical symptoms of Parkinson's disease. PD can affect facial expression (resulting in a masked face), but it does not usually cause facial pain. Ptosis is more commonly seen in conditions like Horner's syndrome, myasthenia gravis, or as a side effect of medications, but it is not a hallmark symptom of Parkinson's disease.

C. Diarrhea and nausea: While gastrointestinal symptoms such as constipation can be seen in Parkinson's disease due to autonomic dysfunction and decreased gut motility, diarrhea and nausea are not typical primary symptoms. In fact, constipation is a more common issue in PD. Nausea could result from the use of medications like levodopa, but it is not a defining feature of the disease itself.

D. Ecchymosis and petechiae: Ecchymosis (bruising) and petechiae (small red or purple spots on the skin) are not characteristic of Parkinson's disease. These findings are more often associated with platelet disorders, bleeding disorders, or vascular conditions. While Parkinson's disease can involve complications like falls (which could lead to bruising), these are not direct symptoms of the disease itself. The primary symptoms involve motor and autonomic dysfunction.

A. Serum potassium of 5.2 mEq/L (normal 3.5 mEq/L-5.3 mEq/L.) B. T wave depression on electrocardiogram C. Heart rate of 90 beats per minute D. Blood pressure of 90/50

Correct Answer is D

Explanation

A. Serum potassium of 5.2 mEq/L: A potassium level of 5.2 mEq/L is slightly elevated but is still within a potentially acceptable range (normal is 3.5-5.3 mEq/L). While elevated potassium can be a concern, particularly in the context of an MI or with certain medications (like potassium-sparing diuretics), this level is not critically high. The nurse should monitor the potassium levels, but this is not an urgent finding requiring immediate reporting unless it increases further or is accompanied by significant symptoms (such as arrhythmias).

B. T wave depression on electrocardiogram (ECG): T wave depression can be a sign of ischemia or injury, which is common in the setting of an acute myocardial infarction. However, T wave changes are expected in this context and do not indicate an immediate emergency. The nurse should continue to monitor the ECG for any progression or worsening of ischemic changes but should prioritize concerns such as hypotension or worsening clinical status over this finding.

C. Heart rate of 90 beats per minute: A heart rate of 90 beats per minute is within normal limits (60-100 beats per minute), especially in the early stages of an MI. Nitroglycerin may cause a reflex tachycardia as a compensatory response to the decreased blood pressure, but a heart rate of 90 bpm is not an alarming finding. The nurse should continue to monitor the heart rate, but it is not the most pressing concern compared to hypotension. 4o mini

D. Blood pressure of 90/50: A blood pressure of 90/50 mmHg is significantly low and could indicate that the client is experiencing hypotension, which is a known side effect of nitroglycerin infusion. Nitroglycerin causes vasodilation, which can reduce blood pressure, especially in clients who are already at risk due to an acute myocardial infarction (MI). Low blood pressure can compromise perfusion to vital organs, including the heart, brain, and kidneys, and may lead to shock if not corrected promptly. This finding should be reported immediately to the healthcare provider, as it may require adjustment of the nitroglycerin dosage or discontinuation of the infusion.

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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:

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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