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 A

Explanation

A. This is the most direct and appropriate question to assess for dysuria. Dysuria is characterized by pain, discomfort, or burning sensation during urination. Asking this question helps the nurse to directly assess if the client is experiencing these symptoms.

B. This question is more relevant for assessing urinary frequency rather than dysuria. It is important for assessing other urinary symptoms but does not specifically address the characteristic pain or discomfort associated with dysuria.

C. This question is pertinent for assessing urinary retention or incomplete emptying of the bladder, which are different concerns from dysuria. It evaluates the client's perception of bladder emptying rather than pain or discomfort during urination.

D. This question is more relevant for assessing urinary hesitancy or urgency, which are related to bladder function but are not specific to dysuria. It addresses issues with urine flow dynamics rather than pain or discomfort during urination.

A. Meeting the client's spiritual needs can help decrease suffering. B. Nurses are the only health professionals who provide this type of holistic care. C. Until spiritual needs are met, physical needs cannot be healed. D. It is important that the nurse's idea of spirituality matches the client's ideas.

Correct Answer is A

Explanation

A. Spiritual care is integral to holistic care. Addressing spiritual needs can provide comfort, meaning, and a sense of peace to clients, which can contribute to a reduction in suffering, both physical and emotional. Spiritual distress can exacerbate physical symptoms and affect overall well-being, so addressing these needs can lead to better outcomes.

B. While nurses play a significant role in providing holistic care, including spiritual care, they are not the sole providers. Spiritual care can be provided by chaplains, spiritual counselors, and other healthcare professionals trained in addressing spiritual needs. However, nurses often have frequent and intimate contact with patients, making them well-positioned to assess and address spiritual concerns and to collaborate with other members of the healthcare team to meet these needs.

C. While addressing spiritual needs can contribute to overall well-being and healing, physical healing does not solely depend on meeting spiritual needs. Physical healing involves medical interventions, treatments, and physiological processes. However, addressing spiritual needs can positively impact a client's emotional and psychological state, which can support the overall healing process.

D. Understanding and respecting the client's own beliefs, values, and preferences regarding spirituality is crucial. Each individual may have unique spiritual beliefs and practices that influence their health beliefs and behaviors. The nurse should approach spiritual care with cultural sensitivity and respect for diversity, ensuring that the care provided aligns with the client's beliefs and preferences.

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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

The nurse is assessing the client for the presence of dysuria. The nurse should ask: "Do you:

Correct Answer is A

Explanation

As a part of care planning, the nurse considers the client's spiritual needs. What is the Rationale for this concern?

Correct Answer is A

Explanation

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