Which of the following is an EARLY sign of patient hypoxia?
Cyanosis.
Bradycardia.
Hypotension.
Agitation.
The Correct Answer is D
Choice A rationale
Cyanosis, a bluish discoloration of the skin and mucous membranes, is a late and ominous sign of hypoxia. It becomes clinically apparent when there are approximately 5 grams per deciliter of desaturated hemoglobin. This indicates a significant reduction in oxygen saturation and severe tissue hypoxia, representing a decompensated physiological state.
Choice B rationale
Bradycardia, a slower than normal heart rate (normal range 60-100 beats per minute for adults), is typically a late sign of hypoxia, particularly in adults. Initially, the body often compensates for hypoxia with tachycardia to increase cardiac output and oxygen delivery. Profound and prolonged hypoxia can depress myocardial function, leading to bradycardia.
Choice C rationale
Hypotension, a low blood pressure (normal range systolic 90-120 mmHg, diastolic 60-80 mmHg), is generally considered a late sign of hypoxia. In the early stages, the sympathetic nervous system may initially increase blood pressure as a compensatory mechanism. However, prolonged or severe hypoxia can lead to myocardial depression and vasodilation, resulting in hypotension.
Choice D rationale
Agitation is an early neurological sign of hypoxia. As oxygen levels decrease, cerebral hypoxia affects brain function, leading to irritability, restlessness, and confusion. The brain is highly sensitive to oxygen deprivation, and these behavioral changes are often among the first indicators of inadequate oxygenation, preceding more overt physiological decompensation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale
Encouraging extensive family visitation in the context of impending demise, while emotionally supportive, does not directly address the physiological mechanisms of intracranial pressure reduction. Increased stimulation and emotional distress can paradoxically elevate ICP by increasing cerebral metabolic demand and blood flow, which is counterproductive to managing an acute neurological crisis.
Choice B rationale
Maintaining the patient's neck in a midline and neutral position is crucial to facilitate optimal venous outflow from the brain. Compression or kinking of the jugular veins due to neck rotation or flexion can impede cerebral venous drainage, leading to an increase in cerebral blood volume and subsequently elevated intracranial pressure.
Choice C rationale
Administering stool softeners helps prevent straining during defecation, a maneuver known as the Valsalva maneuver. The Valsalva maneuver increases intrathoracic and intra-abdominal pressure, which in turn transiently increases central venous pressure and impedes cerebral venous outflow, thereby elevating intracranial pressure.
Choice D rationale
Keeping room curtains open to maximize natural light can increase environmental stimulation, potentially leading to increased cerebral activity and metabolic demand. This heightened activity can result in increased cerebral blood flow and volume, which can contribute to elevated intracranial pressure in a neurologically compromised patient.
Choice E rationale
Elevating the head of the bed (HOB) to 30 degrees promotes venous drainage from the brain by utilizing gravity. This position helps to reduce cerebral blood volume, thereby decreasing intracranial pressure. It also aids in preventing aspiration while maintaining cerebral perfusion pressure.
Correct Answer is ["B","D"]
Explanation
Choice A rationale
A panic attack typically leads to hyperventilation, causing excessive exhalation of carbon dioxide. This results in respiratory alkalosis, characterized by a decreased partial pressure of carbon dioxide (PaCO2) and an elevated pH, due to the rapid elimination of carbonic acid from the body.
Choice B rationale
Morphine overdose depresses the central nervous system, significantly reducing the respiratory drive. This leads to hypoventilation, which causes an accumulation of carbon dioxide (CO2) in the blood. The increased CO2 forms carbonic acid, lowering the blood pH and resulting in respiratory acidosis.
Choice C rationale
Alcohol intoxication primarily affects the central nervous system, leading to respiratory depression similar to opioid overdose. However, severe alcohol intoxication can also cause metabolic acidosis due to lactic acid accumulation from impaired tissue perfusion and metabolism.
Choice D rationale
Sleep apnea causes recurrent episodes of hypoventilation and apnea during sleep. These episodes lead to periods of elevated carbon dioxide (CO2) levels in the blood due to inadequate gas exchange, resulting in intermittent or chronic respiratory acidosis depending on the severity and duration.
Choice E rationale
Cocaine is a stimulant that typically increases respiratory rate and depth. This hyperventilation leads to increased exhalation of carbon dioxide (CO2), resulting in a decrease in PaCO2 and an elevation in blood pH, which is characteristic of respiratory alkalosis.
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