The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

Confusion

Apnea

Cyanosis

Dysrhythmias

Answer and Explanation

The Correct Answer is A

A. Confusion can be an early sign of hypoxia, especially when oxygen delivery to the brain is compromised. Inadequate oxygenation can affect cognitive function and mental status, leading to confusion. This occurs because the brain is highly sensitive to changes in oxygen levels.

B. Apnea refers to the absence of breathing. While severe hypoxia can lead to respiratory arrest and apnea, it is not typically an early manifestation of hypoxia. Early hypoxia is characterized by attempts to increase ventilation to compensate for decreased oxygen levels, rather than complete cessation of breathing.

C. Cyanosis occurs when there is a bluish discoloration of the skin and mucous membranes due to deoxygenated hemoglobin in the blood. Cyanosis is a late sign of hypoxia and usually indicates significant oxygen deprivation. It is not typically seen in early hypoxia stages.

DDysrhythmias (irregular heart rhythms) can occur as a result of hypoxia, especially if the heart muscle is not receiving enough oxygen. However, dysrhythmias are generally considered a later manifestation of hypoxia, as the heart attempts to compensate for decreased oxygen delivery.

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Correct Answer is D

Explanation

D. This statement exemplifies the ethical principle of fidelity, also known as faithfulness or commitment. Fidelity involves keeping promises, being reliable, and fulfilling commitments made to patients. By returning promptly with the pain medication as promised, the nurse demonstrates fidelity by honoring their commitment to the patient's care and comfort.

A. This statement reflects the ethical principle of justice, which emphasizes fairness and equality in treatment for all patients. Justice ensures that resources and treatments are distributed fairly among individuals.

B This statement demonstrates the ethical principle of nonmaleficence, which focuses on preventing harm and minimizing risks to patients. It emphasizes the nurse's commitment to avoiding harm or injury to the patient.

C. This statement relates to truth-telling or veracity, which involves providing honest and accurate information to patients about their care, procedures, and potential outcomes. It reflects transparency and respect for patient autonomy.

A. enhance abilities to give quality care. B. encourage participation of clients in nursing research. C. analyze phenomena of importance to nursing. D. consider options for nursing actions.

Correct Answer is A

Explanation

A. By critically thinking about client care, nurses can assess situations, analyze data, evaluate options, and make informed decisions that contribute to the delivery of high-quality care. Critical thinking helps nurses identify priorities, anticipate potential complications, and adapt care plans based on individual client needs and responses.

B. While critical thinking is important in research and evidence-based practice, its primary role in client care is to ensure that nursing interventions are well-reasoned, evidence-based, and tailored to meet the specific needs of clients. While clients may benefit indirectly from evidence-based care resulting from nursing research, client care primarily focuses on immediate clinical decision-making and management.

C. Critical thinking involves analyzing various aspects of client care, including physiological, psychological, and social phenomena. By critically analyzing these phenomena, nurses can understand underlying issues, identify contributing factors to health conditions, and determine appropriate nursing interventions to promote health and well-being. This process helps nurses make sense of complex client situations and provide holistic care.

D. Critical thinking enables nurses to consider multiple options or strategies for nursing actions. By critically evaluating these options based on client assessment data, evidence-based practice guidelines, and ethical principles, nurses can make informed decisions about the most effective and appropriate interventions for their clients. This ensures that nursing care is individualized and responsive to the unique needs and preferences of each client.

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The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is considering ethical principles during rounds. Which nursing statement demonstrates the principle of fidelity?

Correct Answer is D

Explanation

what is the primary reason for a nurse to critically think about client care?

Correct Answer is A

Explanation

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