A nurse is assessing a patient following the removal of the patient’s endotracheal tube. Which finding should the nurse report to the provider?

Choice A rationale:

Chronic pain can manifest in various behavioral and physical symptoms, including restlessness, pacing, grimacing, and other facial expressions of pain. These behaviors are often unconscious attempts to cope with or distract from the pain.

They may also reflect the emotional distress that often accompanies chronic pain. Patients may feel frustrated, anxious, or even depressed due to the persistent nature of their pain and its impact on their lives.

It's crucial for nurses to recognize these behavioral signs of pain, as patients may not always readily report their pain verbally. By observing these behaviors, nurses can assess the patient's pain level more accurately and provide appropriate interventions.

Choice B rationale:

Chronic pain is defined as pain that persists for longer than three months, often for much longer. It is not limited and short in duration.

This distinguishes it from acute pain, which is typically associated with an injury or illness and resolves within a few days or weeks.

Choice C rationale:

While some patients with chronic pain may have physical signs of tissue injury, this is not always the case. Chronic pain can also be caused by nerve damage, inflammation, or changes in the central nervous system.

In some cases, the underlying cause of chronic pain may be unknown.

Choice D rationale:

Although chronic pain may not always cause a significant change in vital signs, it can still be a very real and debilitating experience for patients.

Vital signs, such as heart rate, blood pressure, and respiratory rate, are often more sensitive to acute pain.

Nurses should not rely solely on vital signs to assess chronic pain. Instead, they should consider the patient's self-report of pain, behavioral cues, and other factors.

Choice A rationale:

Cellular hypoxia occurs when cells do not receive enough oxygen to meet their metabolic demands. Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues. A hemoglobin level of 10.8 g/dL is below the normal range for adults (14-18 g/dL), indicating that the client has anemia. Anemia reduces the oxygen-carrying capacity of the blood, which can lead to cellular hypoxia.

Here is a detailed explanation of how anemia can lead to cellular hypoxia:

Decreased oxygen-carrying capacity: Anemia results in fewer red blood cells or reduced hemoglobin levels within those cells. As a consequence, the blood's ability to transport oxygen to the tissues is diminished.

Impaired oxygen delivery: Oxygen is transported to the tissues through the bloodstream, attached to hemoglobin within red blood cells. With fewer red blood cells or reduced hemoglobin, the delivery of oxygen to the tissues is compromised.

Decreased oxygen availability at the cellular level: As oxygen delivery is impaired, less oxygen is available to the cells for metabolic processes. This insufficient oxygen supply leads to cellular hypoxia.

Impaired cellular function: Cells require oxygen to produce energy through a process called aerobic respiration. Cellular hypoxia disrupts this process, leading to impaired cellular function.

Tissue and organ dysfunction: When a significant number of cells within a tissue or organ experience hypoxia, the function of that tissue or organ can be compromised. This can manifest in various symptoms and complications, depending on the affected organs.

Common signs and symptoms of cellular hypoxia:

Fatigue Weakness

Shortness of breath Pale skin

Dizziness Headache Chest pain

Tachycardia (rapid heart rate) Cognitive impairment