A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?
Metallic taste in mouth
Facial flushing
Muscle twitching
Periorbital edema
The Correct Answer is C
A. Metallic taste in the mouth:
This is not a typical finding of oxygen toxicity. Metallic taste may be associated with other factors but is not a specific indicator of oxygen toxicity.
B. Facial flushing:
Facial flushing is not a typical finding in oxygen toxicity. It is more commonly associated with other conditions, such as certain allergic reactions or vasodilation.
C. Muscle twitching
Muscle twitching, also known as myoclonus, is a recognized symptom of central nervous system oxygen toxicity. High concentrations of oxygen, particularly at increased pressures, can cause neurotoxic effects leading to muscle twitching, dizziness, and even convulsions.
D. Periorbital edema:
Periorbital edema is not a common manifestation of oxygen toxicity. It is more commonly associated with conditions related to fluid balance or kidney function.
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Related Questions
Correct Answer is D
Explanation
A. “I understand your fears, I was a smoker also.”
While sharing personal experiences can sometimes be relatable, it may not be the most therapeutic response in this situation. The focus should be on the client's feelings and concerns rather than the nurse's personal history.
B. “Don’t worry. The important thing is you have now quit smoking.”
Dismissing the client's fear with a "don't worry" statement may invalidate the client's emotions. It's important to acknowledge and address the client's feelings rather than downplaying them.
C. “Your doctor is a great surgeon. You will be fine.”
While it's positive to express confidence in the medical team, this response does not directly address the client's emotional concerns. The client's fear may extend beyond the surgical aspect, and it's essential to explore and discuss those fears.
D. “It’s okay to feel scared. Let’s talk about what you are afraid of.”
This response is the most therapeutic as it acknowledges the client's emotions, validates the fear, and opens the door for further communication. It invites the client to express her concerns and allows the nurse to provide support and information based on the client's specific fears.
Correct Answer is C
Explanation
A. The AP’s rapport with clients:
While a positive rapport with clients is valuable, it is not a direct factor in determining whether an AP is suitable for a specific task based on the five rights of delegation.
B. The AP’s ability to complete the task without assistance:
The ability to complete a task without assistance is relevant but does not guarantee that the AP has the necessary knowledge and skill for the task. The focus should be on competence rather than independence.
C. The AP has the knowledge and skill to perform the task
When considering the five rights of delegation, one of the crucial factors is ensuring that the assistive personnel (AP) has the knowledge and skill necessary to perform the delegated task safely and effectively. Delegated tasks should align with the AP's competence and training to maintain the safety and well-being of the client.
D. The AP’s ability to prioritize:
Prioritization skills are important for healthcare providers, but the focus of delegation, as per the five rights, is on the AP's competence to perform the specific task.
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