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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. S–Situation: The situation includes immediate information about why the client is being transferred or receiving care, such as current symptoms, diagnosis, or presenting complaint. It does not include upcoming procedures or equipment needs.
B. R–Recommendations: Recommendations include what actions or interventions are needed next, such as upcoming tests, procedures, or equipment setup. Mentioning the need for a suction setup and an endoscopy reflects planning for ongoing care and falls under this category.
C. B–Background: Background refers to the client's medical history, diagnosis, and events leading up to the current situation. It gives context but does not include plans for future care.
D. A–Assessment: Assessment includes clinical findings, vital signs, laboratory results, and how the client is currently presenting. It focuses on objective and subjective data, not future recommendations or equipment planning.
Correct Answer is D
Explanation
A. Only the flail segment pulling inward during expiration: During expiration, the pressure inside the chest decreases, and typically the chest wall recoils outward. A flail segment moves abnormally in the opposite direction during inspiration, not expiration.
B. The entire chest pulling inward during expiration: Inward movement of the entire chest during expiration is not characteristic of flail chest. This could suggest severe respiratory distress or chest wall weakness, but not the hallmark sign of flail chest.
C. The entire chest pushing outward during inspiration: This is a normal movement during inspiration and not specific to flail chest. In flail chest, the abnormality is seen in the flail segment, not the entire chest.
D. Only the flail segment pulling inward during inspiration: This is the classic finding in flail chest. Due to the broken ribs losing continuity with the rest of the rib cage, the flail segment moves paradoxically—inward during inspiration and outward during expiration—opposite to the normal chest wall motion.
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