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
The correct answer is Choice D.
Choice A rationale: Documenting the event in the client’s progress notes is not the most appropriate action in this situation. The client’s progress notes should contain information about the client’s health status and care, not about staff behavior. Furthermore, documenting this incident in the client’s notes could potentially violate the client’s privacy if the notes are accessed by individuals who do not need to know about the incident.
Choice B rationale: Submitting an incident report to the risk manager is not the most appropriate action in this situation. Incident reports are typically used for events that have caused or have the potential to cause harm to a client, such as medication errors or falls. In this case, while the APs’ behavior is inappropriate, it has not caused harm to the client.
Choice C rationale: Informing the client of the APs’ actions is not the most appropriate action in this situation. Doing so could unnecessarily worry or upset the client. The nurse’s role is to advocate for the client and protect their privacy and dignity, which includes not sharing information about inappropriate staff behavior with the client.
Choice D rationale: Telling the APs to stop the conversation is the most appropriate action in this situation. The nurse has a professional responsibility to address inappropriate behavior by other healthcare team members. Discussing a client in a public area, such as the nurses’ station, is a breach of client confidentiality. The nurse should remind the APs of the importance of maintaining client confidentiality and direct them to stop the conversation.
Correct Answer is A
Explanation
Choice A rationale:
Inquiring about the client's bedtime routine is the nurse's priority because it directly addresses the client's reported problem of insomnia due to increased stress. Understanding the client's routine can help identify factors contributing to sleep difficulties and guide the development of an appropriate plan of care.
Choice B rationale:
Recommending that the client go for a walk every morning may be a helpful intervention, but it does not directly address the client's immediate concern of insomnia. It's important to first assess the client's current situation and then provide tailored interventions.
Choice C rationale:
Instructing the client to turn off the television before bedtime is a good sleep hygiene practice, but it may not be the priority when the client is experiencing acute insomnia due to increased stress. The nurse should first gather information about the client's specific situation.
Choice D rationale:
Encouraging the client to listen to soft music at the onset of stress is a useful relaxation technique, but it may not be the priority in this case. The nurse should focus on addressing the client's insomnia by identifying contributing factors and implementing appropriate interventions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.