The nurse is assessing a patient with multiple traumas, who is at risk for developing respiratory distress syndrome. What assessment finding does the nurse expect as an early sign of respiratory distress syndrome?

Inspiratory crackles

Bilateral wheezing

Increased respiratory rate

Intercostal retractions

Answer and Explanation

The Correct Answer is C

A. Inspiratory crackles: Crackles typically appear later in respiratory distress syndrome (RDS) due to alveolar collapse and fluid accumulation. Early in the syndrome, the alveoli are still partially functional, so crackles may not yet be present. Relying on this finding could delay recognition of the initial compromise.

B. Bilateral wheezing: Wheezing results from bronchospasm or airway obstruction and is more characteristic of conditions like asthma or COPD exacerbations. It is not an early sign of RDS, which primarily involves alveolar collapse, decreased surfactant, and impaired gas exchange rather than bronchial constriction.

C. Increased respiratory rate: Tachypnea is an early compensatory response to hypoxemia and carbon dioxide retention in RDS. The body attempts to maintain oxygenation and ventilation by increasing the respiratory rate before overt signs such as crackles or retractions appear, making it a key early indicator.

D. Intercostal retractions: Retractions indicate increased work of breathing and usually occur later in the progression of respiratory distress. They reflect significant respiratory muscle fatigue and impending respiratory failure rather than an initial compensatory change.

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Correct Answer is C

Explanation

A. Cool, clammy skin: Cool, clammy skin is characteristic of hypovolemic or cardiogenic shock due to peripheral vasoconstriction. In neurogenic shock, loss of sympathetic tone causes vasodilation, so the skin is typically warm and dry rather than cool and clammy.

B. Hypotension: Hypotension is present in neurogenic shock due to systemic vasodilation and relative hypovolemia. While it is an important finding, it is not specific for neurogenic shock and can be seen in multiple types of shock, making it less definitive as a distinguishing feature.

C. Bradycardia: Neurogenic shock involves loss of sympathetic innervation below the level of spinal cord injury, resulting in unopposed parasympathetic stimulation. This leads to bradycardia in combination with hypotension, a hallmark finding that differentiates neurogenic shock from other shock types, which usually cause tachycardia.

D. Decreased urinary output: Oliguria may occur in neurogenic shock due to hypotension and reduced renal perfusion. However, it is a secondary effect rather than a primary diagnostic sign. Early recognition relies on the combination of hypotension with bradycardia and vasodilation.

A. Decreased seizure activity B. Decreased inflammatory response C. Decreased cerebral edema D. Decreased cerebral metabolism

Correct Answer is C

Explanation

A. Decreased seizure activity: Mannitol does not have anticonvulsant properties. While reducing intracranial pressure may indirectly reduce seizure risk in some patients, its primary mechanism is not seizure control, so this is not the expected therapeutic outcome.

B. Decreased inflammatory response: Mannitol does not act on inflammatory pathways. It is an osmotic diuretic and does not reduce inflammation in brain tissue or systemic conditions. Anti-inflammatory medications are used for that purpose.

C. Decreased cerebral edema: Mannitol is an osmotic diuretic that draws water out of edematous brain tissue into the intravascular space, reducing intracranial pressure. This decrease in cerebral edema improves cerebral perfusion and oxygenation, which is the primary therapeutic goal in unconscious patients with increased intracranial pressure.

D. Decreased cerebral metabolism: Mannitol does not directly alter cerebral metabolic rate. Interventions like hypothermia or sedatives affect cerebral metabolism, but mannitol’s effect is through osmotic fluid shifts rather than metabolic modulation.

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The nurse is assessing a patient with multiple traumas, who is at risk for developing respiratory distress syndrome. What assessment finding does the nurse expect as an early sign of respiratory distress syndrome?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with massive trauma and possible spinal cord injury is admitted to the emergency department. The nurse suspects that the patient may be experiencing neurogenic shock based on which assessment finding?

Correct Answer is C

Explanation

The physician prescribes IV mannitol for an unconscious patient. The nurse would expect the therapeutic effect of this drug to result in which outcome?

Correct Answer is C

Explanation

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