A client in the emergency department is experiencing an acute asthma exacerbation, which has not improved with albuterol nebulizer treatments. The client is obviously struggling to breathe. The nurse anticipates that intubation and mechanical ventilation will be needed based on which of the following assessment findings?
Tachycardia
Anxiety
Hypotension
Loud expiratory wheezing
The Correct Answer is C
A. Tachycardia (rapid heart rate) can occur in response to hypoxia (low oxygen levels), stress, or as a side effect of medications like albuterol. While tachycardia is a concerning sign in the context of an asthma exacerbation, it alone does not directly indicate the need for intubation and mechanical ventilation. It is often managed by addressing the underlying respiratory distress and improving oxygenation.
B. Anxiety is common in patients struggling to breathe, as they may feel frightened or panicked due to their difficulty breathing. However, anxiety itself is not an indicator for intubation and mechanical ventilation. It is a symptom of respiratory distress but does not directly assess the severity of the physiological need for mechanical support.
C. Hypotension (low blood pressure) in the context of an asthma exacerbation can be a sign of severe illness, possibly indicating shock or severe respiratory distress leading to reduced cardiac output. While hypotension is a serious concern, it is less directly related to the immediate need for intubation and mechanical ventilation compared to other indicators of respiratory failure.
D. Loud expiratory wheezing indicates significant airway obstruction but does not necessarily reflect the need for intubation and mechanical ventilation. Wheezing can be a sign of severe asthma but may not be sufficient on its own to necessitate intubation if the patient can still maintain adequate oxygenation and ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While vitamin A can interact with some medications, it does not have a significant effect on verteporfin.
B. Verteporfin does not typically affect blood sugar levels.
C. Verteporfin is usually administered intravenously, so it is not taken orally.
D. Verteporfin is a photosensitizing agent used in photodynamic therapy for age-related macular degeneration. After treatment with verteporfin, the client should avoid sunlight and other intense light for several days to prevent a severe sunburn-like reaction. This is because verteporfin makes the skin and eyes more sensitive to light.
Correct Answer is B
Explanation
A. Parkinson's disease is not generally considered to be caused by an autoimmune reaction or a recent infection. Autoimmune reactions leading to neurodegeneration are more commonly associated with other conditions such as multiple sclerosis, not Parkinson's disease.
B. The exact cause of Parkinson's disease is indeed unknown, but research suggests that it results from a combination of genetic predispositions and environmental factors. Genetic mutations may contribute to the development of Parkinson's disease in some individuals, while environmental factors such as exposure to certain toxins or other external influences might also play a role. The interplay between these factors is still being studied.
C. There is no evidence to support the idea that Parkinson's disease is caused by the reactivation of a virus affecting cranial nerve VII (the facial nerve). Parkinson's disease involves the degeneration of dopamine-producing neurons in the brain, not specifically related to viral reactivation or isolated to cranial nerve VII.
D. Demyelination of nerves is characteristic of multiple sclerosis, not Parkinson's disease. In Parkinson's disease, the primary issue is the loss of dopamine-producing neurons in the substantia nigra of the brain, not demyelination. This option describes a different pathological process unrelated to Parkinson's disease.
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