A nurse is assisting with the care of a client.
Vital Signs.
1330: Temperature 36.8 °C (98.2 °F) Heart rate 88/min.
Respiratory rate 16/min.
Blood pressure 110/64 mm Hg. 1345: Oxygen saturation 96% on 3 L/min via simple face mask.
Temperature 37 °C (98.6 °F) Heart rate 112/min.
Respiratory rate 20/min.
Blood pressure 108/60 mm Hg. 1400: Oxygen saturation 94% on 3 L/min via simple face mask.
Temperature 38.3 °C (101 °F) Heart rate 152/min.
For each data collection finding, click to specify if the finding is consistent with malignant hyperthermia, latex allergy, or hypovolemic shock.
Each finding may support more than 1 disease process.
Wheezes
Muscle rigidity
Urticaria
Hypercapnia
Tachycardia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B,C"}}
Wheezes: This finding may indicate a latex allergy, as wheezing is a sign of respiratory distress caused by an allergic reaction to latex proteins. Wheezes are not typical of malignant hyperthermia or hypovolemic shock.
Muscle rigidity: This finding is a hallmark of malignant hyperthermia, as it reflects the excessive calcium release and muscle contraction triggered by certain anesthetic agents. Muscle rigidity is not a feature of latex allergy or hypovolemic shock.
Urticaria: This finding is a common manifestation of latex allergy, as urticaria (hives) is a type of skin rash caused by an allergic reaction to latex proteins. Urticaria is not associated with malignant hyperthermia or hypovolemic shock.
Hypercapnia: This finding is indicative of malignant hyperthermia, as hypercapnia (high carbon dioxide levels in the blood) is a result of increased metabolism and oxygen consumption due to muscle rigidity and fever. Hypercapnia is not usually seen in latex allergy or hypovolemic shock, unless there is severe respiratory compromise.
Tachycardia: This finding can be present in all three disease processes, as tachycardia (fast heart rate) is a nonspecific response to stress, fever, pain, hypoxia, or hypovolemia. However, tachycardia is more pronounced and persistent in malignant hyperthermia and hypovolemic shock than in latex allergy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Bradycardia. Heparin is an anticoagulant medication that primarily affects the blood's clotting ability. Bradycardia, or a slow heart rate, is not a common side effect of heparin. Therefore, it is not a typical adverse effect to report in this context.
Choice B rationale:
Anorexia. Anorexia, or a loss of appetite, is not a common adverse effect of heparin. Heparin's primary mode of action is to prevent blood clot formation, and it does not directly affect appetite.
Choice C rationale:
Weight gain. Weight gain is not a typical adverse effect of heparin. Heparin's mechanism of action does not lead to changes in body weight. Weight gain could be related to other factors but is not directly associated with heparin administration.
Choice D rationale:
Epistaxis. Epistaxis, or nosebleeds, can be a sign of a bleeding disorder or an adverse effect of anticoagulant therapy like heparin. Heparin can increase the risk of bleeding, including nosebleeds, and should be monitored closely for this adverse effect. It is important to report any signs of excessive bleeding to the healthcare provider as they may need to adjust the dosage or monitor the patient more closely.
Correct Answer is D
Explanation
Choice A rationale:
Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.
Choice B rationale:
Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.
Choice C rationale:
Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.
Choice D rationale:
This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.
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