A nurse is assessing a client who has respiratory failure. Which of the following manifestations should the nurse identify as indicative of severe hypercapnia?
Cyanosis
Arrhythmias
Asterixis
Tachycardia
The Correct Answer is C
A. Cyanosis: Cyanosis is a late sign of hypoxemia, not specifically hypercapnia. It indicates poor oxygenation of tissues but does not directly reflect elevated carbon dioxide levels in the blood.
B. Arrhythmias: Arrhythmias may occur in respiratory failure due to hypoxemia or acid-base disturbances. However, they are not the most specific indicator of severe hypercapnia and can result from a range of metabolic or cardiac causes.
C. Asterixis: Asterixis, or "flapping tremor," is a neurologic manifestation of severe hypercapnia and altered mental status. It results from elevated CO₂ levels affecting brain function and is often seen in CO₂ narcosis or advanced respiratory failure.
D. Tachycardia: Tachycardia is a common compensatory response to hypoxia or hypercapnia, but it is nonspecific. It can be seen in many conditions and is not a definitive sign of severe carbon dioxide retention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A decrease in intracellular fluid volume: A reduction in intracellular fluid volume often results from hypertonic conditions in the extracellular space, which can draw water out of cells. This shift can actually increase serum osmolality rather than decrease it.
B. An increase in hydrostatic pressure: Increased hydrostatic pressure promotes fluid movement from the vascular space into the interstitial tissues, contributing to edema. However, this does not significantly impact the concentration of solutes in the serum and therefore does not directly cause a decrease in osmolality.
C. An increase in serum sodium: Sodium is the main contributor to serum osmolality, so an increase in serum sodium raises osmolality. This is the opposite of what occurs in heart failure, where sodium levels are often diluted due to fluid retention.
D. An increase in vascular fluid volume: In heart failure, the kidneys retain fluid in response to decreased cardiac output, expanding the vascular volume. This excess water dilutes the concentration of solutes in the blood, such as sodium, leading to a decrease in serum osmolality.
Correct Answer is D
Explanation
A. "Clients who have BRCA1 or BRCA2 gene changes have a decreased risk of breast cancer.":
Individuals with BRCA1 or BRCA2 mutations actually have an increased risk of developing breast cancer, not a decreased one. These gene mutations significantly increase the likelihood of breast and ovarian cancers.
B. "Clients should begin screening mammography annually by the age of 30 years old.":
The general recommendation is to begin annual mammography screenings at age 40 for average-risk women, with earlier screening only recommended for those at high risk due to family history or genetic factors.
C. "Breastfeeding increases the risk of breast cancer in women over 40 years of age.":
Breastfeeding has been shown to lower the risk of breast cancer, especially for women who breastfeed for longer durations. It does not increase the risk of developing breast cancer.
D. "Breast cancer can occur in any part of the breast, but ductal breast cancer is most common.":
Breast cancer can develop in any part of the breast, but ductal carcinoma, which originates in the milk ducts, is the most common form of breast cancer.
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