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 B
Explanation
Choice A rationale:
Instructing parents to avoid bringing fresh flowers into the room is not the primary intervention for a child with Clostridium difficile. While it is essential to maintain a clean environment, the most critical action is to implement proper infection control measures.
Choice B rationale:
This is the correct answer. Initiating contact precautions is crucial when caring for a child with Clostridium difficile. This includes using gloves and gowns to prevent the spread of the bacteria to others.
Choice C rationale:
Using a HEPA filtration system in the room is not the first-line intervention for managing Clostridium difficile. While it can help maintain air quality, it does not directly address the transmission of the bacteria.
Choice D rationale:
Using an N95 respirator is not the primary action in caring for a child with Clostridium difficile. Contact precautions, such as gloves and gowns, are more critical to prevent the spread of infection.
Correct Answer is D
Explanation
The correct answer is d. Hallucinations.
Choice A reason: Hypothermia is not typically associated with MDMA use. Instead, MDMA can cause hyperthermia due to its stimulant effects.
Choice B reason: Muscle weakness is not a common effect of MDMA. The drug is more likely to cause increased energy and endurance.
Choice C reason: Somnolence, or a strong desire for sleep, is unlikely with MDMA use as it is a stimulant and tends to increase alertness.
Choice D reason: Hallucinations are a known effect of MDMA use, where users may experience distortions in perception. Methylenedioxy-methamphetamine (MDMA) is known to cause perceptual changes, including hallucinations.
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