The nurse provides care for a client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?

Cyanosis

Wheezing

Decreased level of consciousness

Frequent coughing

Answer and Explanation

The Correct Answer is C

Choice A reason: Cyanosis, a bluish skin discoloration, indicates hypoxemia in COPD due to impaired gas exchange in damaged alveoli. While concerning, it is a common chronic symptom and not immediately life-threatening unless rapidly worsening. Decreased level of consciousness signals severe hypoxia affecting cerebral oxygenation, requiring urgent reporting over stable cyanosis.

Choice B reason: Wheezing results from airway obstruction in COPD, caused by bronchoconstriction and mucus accumulation, reducing airflow. It’s a chronic symptom managed with bronchodilators. While important, it does not indicate acute decompensation like decreased consciousness, which reflects critical cerebral hypoxia and requires immediate intervention to prevent brain damage.

Choice C reason: Decreased level of consciousness indicates severe hypoxia in COPD, as low oxygen saturation impairs cerebral function. Brain cells require constant oxygen for ATP production via aerobic metabolism. Hypoxia reduces cerebral perfusion, causing confusion or unresponsiveness, signaling a life-threatening emergency. This finding warrants immediate reporting to address acute respiratory failure.

Choice D reason: Frequent coughing in COPD results from mucus production and airway irritation, a common chronic symptom. It aids in clearing secretions but does not indicate acute decompensation. Unlike decreased consciousness, which reflects severe cerebral hypoxia, coughing is less urgent and managed with expectorants or airway clearance techniques, not immediate reporting.

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Correct Answer is C

Explanation

Choice A reason: Stating that talking to the client makes the nurse feel better is inappropriate as it centers on the nurse's emotions rather than the patient’s needs. Communication with dying patients supports dignity, assuming they may retain awareness, which aligns with patient-centered end-of-life care principles.

Choice B reason: Suggesting that talking reduces the nurse’s fear of death is unprofessional and irrelevant. The focus should be on the patient’s potential awareness and dignity. This response dismisses the therapeutic value of communication, which may comfort the patient, per palliative care and psychosocial support guidelines.

Choice C reason: Believing the patient can hear while alive is accurate, as studies suggest hearing persists in dying patients, supporting communication to provide comfort and dignity. This response reflects evidence-based practice, respecting the patient’s potential awareness and aligns with compassionate end-of-life care, per palliative care principles.

Choice D reason: Claiming the family requested talking is inaccurate and deflects responsibility. The rationale should be based on the patient’s potential to hear, supporting dignity. This response lacks a clinical basis and undermines the nurse’s professional judgment in providing meaningful end-of-life communication, per nursing ethics.

A. Cranial nerve I B. Cranial nerves II and III C. Cranial nerve VII D. Cranial nerve VIII

Correct Answer is C

Explanation

Choice A reason: Cranial nerve I (olfactory) assesses smell, not facial movements. Smiling or frowning involves facial muscles, unrelated to olfactory function. Testing nerve I involves odor identification, not motor actions, making it irrelevant to this assessment, per cranial nerve examination protocols.

Choice B reason: Cranial nerves II (optic) and III (oculomotor) control vision and eye movement, not facial expressions. Actions like smiling or puffing cheeks involve facial muscles, not pupil response or gaze, which are tested for II and III, per neurological assessment standards.

Choice C reason: Cranial nerve VII (facial) controls facial expressions, including smiling, frowning, wrinkling the forehead, and puffing cheeks. Testing these actions assesses motor function, confirming nerve integrity. This is a key part of neurological exams, detecting deficits like Bell’s palsy, per cranial nerve assessment guidelines.

Choice D reason: Cranial nerve VII (vestibulocochlear VIII (auditory) assesses hearing and balance, not facial movements. Actions like smiling or puffing cheeks are unrelated to auditory or vestibular function, making this nerve irrelevant to the described assessment, per neurological examination protocols.

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The nurse provides care for a client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While caring for a client near end of life, a nurse talks to the client. An unlicensed assistive personnel asks why the nurse is talking to someone who is dying. Which response is accurate?

Correct Answer is C

Explanation

During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is affected? being tested?

Correct Answer is C

Explanation

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