The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

Hypoxia not responsive to oxygen therapy

Elevated lactate levels

Metabolic alkalosis

Severe, unexplained electrolyte imbalance

Answer and Explanation

The Correct Answer is A

Choice A reason:

Hypoxia not responsive to oxygen therapy is a hallmark early sign of ARDS. ARDS is characterized by acute onset of hypoxemia that does not improve with supplemental oxygen. This refractory hypoxemia is due to severe inflammation and increased permeability of the alveolar-capillary barrier, leading to pulmonary edema and impaired gas exchange.

Choice B reason:

Elevated lactate levels can indicate tissue hypoxia and metabolic stress, which are concerning findings in critically ill patients. However, elevated lactate is not specific to ARDS and can be seen in various conditions, including sepsis and shock. It is not the primary early indicator of ARDS.

Choice C reason:

Metabolic alkalosis is not typically associated with ARDS. ARDS usually involves respiratory failure, which may lead to respiratory acidosis. Metabolic alkalosis can occur in other conditions, such as excessive loss of gastric acid or diuretic use, but it is not an early sign of ARDS.

Choice D reason:

Severe, unexplained electrolyte imbalance can occur in critically ill patients but is not specific to ARDS. Electrolyte imbalances can result from various factors, including fluid shifts, renal dysfunction, and medication effects. These imbalances do not serve as an early diagnostic indicator of ARDS.

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Correct Answer is A

Explanation

Choice A reason:

Flaccid paralysis and lack of sensation below the level of the injury are classic signs of spinal shock. Spinal shock is characterized by a temporary loss of all reflexes, motor, and sensory activity below the level of injury, which typically occurs immediately following the injury. Recognizing these signs is crucial for the timely management of the condition.

Choice B reason:

Hypotension, bradycardia, and warm extremities are more indicative of neurogenic shock rather than spinal shock. Neurogenic shock results from the loss of sympathetic tone following a spinal cord injury, leading to cardiovascular changes. These signs do not specifically indicate spinal shock.

Choice C reason:

The presence of hyperactive reflex activity below the level of the injury is not associated with spinal shock. Spinal shock involves the loss of reflex activity rather than hyperactivity. Hyperactive reflexes might develop later as the spinal cord recovers from the initial shock phase.

Choice D reason:

Severe headache, hypertension, and flushed face are symptoms more commonly associated with autonomic dysreflexia, not spinal shock. Autonomic dysreflexia occurs in patients with spinal cord injuries at or above the T6 level and is a response to a noxious stimulus below the level of injury. These symptoms are not indicative of spinal shock.

A. Palpate the bladder for distention. B. Initiate oxygen via a nasal cannula. C. Place the patient in a supine position. D. Administer a prescribed beta-blocker.

Correct Answer is A

Explanation

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

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The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

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Naxlex Comprehensive Predictor Exams

A patient with a neck fracture at the C3 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During the initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding:

Correct Answer is A

Explanation

A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Correct Answer is A

Explanation

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