A nurse is caring for a client who has respiratory failure due to ventilation-perfusion (V/Q) mismatch. The nurse should recognize that the client most likely has which of the following conditions?
Flail chest
Emphysema
Congestive heart failure
Guillain-Barré syndrome
None
None
The Correct Answer is B
Choice A Reason:
Flail chest is incorrect. Flail chest is a condition characterized by multiple rib fractures, causing instability in the chest wall. While it can lead to respiratory distress, it doesn't directly cause ventilation-perfusion (V/Q) mismatch. Instead, it impairs the mechanics of breathing by compromising chest wall integrity.
Choice B Reason:
Emphysema is a chronic obstructive pulmonary disease (COPD) where the alveolar walls are destroyed, leading to a loss of surface area for gas exchange. This results in areas of the lungs that are well-perfused but poorly ventilated, causing a V/Q mismatch. The damage to alveoli leads to impaired ventilation, while blood flow may still be adequate, leading to hypoxemia (low oxygen levels in the blood).
Choice C Reason:
CHF primarily affects the heart’s ability to pump blood effectively, leading to pulmonary congestion and impaired gas exchange. However, it typically causes diffusion defects rather than a direct ventilation-perfusion mismatch. V/Q mismatch may occur secondary to pulmonary edema, but it’s not the primary mechanism of respiratory failure in CHF.
Choice D Reason:
Guillain-Barré syndrome is incorrect. Guillain-Barré syndrome (GBS) is a neurological disorder that affects the peripheral nervous system, leading to muscle weakness and paralysis. While respiratory muscle weakness can occur in GBS, it doesn't directly cause ventilation-perfusion (V/Q) mismatch. GBS primarily affects nerve function rather than lung function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Drooling is inappropriate. Drooling, also known as sialorrhea, is a common symptom in Parkinson's disease due to impaired swallowing and reduced control of the muscles involved in saliva production. Anticholinergic medications can exacerbate dry mouth, which may contribute to drooling. However, drooling is not typically a side effect that would be specifically associated with anticholinergic use.
Choice B Reason:
Anhidrosis is appropriate. Anhidrosis refers to the inability to sweat normally. Anticholinergic medications can inhibit sweating by blocking the action of acetylcholine on sweat glands, leading to decreased sweating and potentially causing hyperthermia. Anhidrosis is a potential side effect of anticholinergic agents and should be reported to the healthcare provider due to the risk of overheating.
Choice C Reason:
Tremors is inappropriate. Tremors are a common symptom of Parkinson's disease and are typically not caused by anticholinergic medications. In fact, anticholinergic agents are often prescribed to help reduce tremors in individuals with Parkinson's disease. Tremors would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.
Choice D Reason:
Rigidity is inappropriate. Rigidity, or stiffness of the muscles, is a characteristic symptom of Parkinson's disease resulting from the loss of dopamine-producing neurons in the brain. While anticholinergic medications can help alleviate some symptoms of Parkinson's disease, they are not typically associated with rigidity. Rigidity would not be considered an adverse effect that the client should report in the context of anticholinergic therapy.
Correct Answer is C
Explanation
Choice A Reason:
Decreased mucus production contributes to airway constriction: This statement is incorrect. Bronchospasm does not decrease mucus production; instead, it primarily affects the smooth muscles surrounding the bronchioles, leading to their constriction and narrowing of the airways. Increased mucus production, often accompanied by inflammation, can contribute to airway obstruction in conditions like asthma.
Choice B Reason:
Inflammation is reduced due to airway diameter: This statement is incorrect. Bronchospasm typically occurs in the setting of inflammation in conditions such as asthma. Constriction of the airways during bronchospasm exacerbates the inflammation and can further narrow the airways, leading to symptoms such as wheezing and dyspnea.
Choice C Reason:
Bronchospasm occurs when there is inflammation, edema, and excess mucus: This statement is partially correct. Bronchospasm often occurs in the presence of inflammation, edema, and excess mucus production, as seen in conditions like asthma. These factors contribute to airway hyperresponsiveness, leading to bronchospasm and airway narrowing.
Choice D Reason:
Airway obstruction occurs due to thinning mucus: This statement is incorrect. Airway obstruction in conditions like asthma is primarily due to bronchospasm, inflammation, and excessive mucus production, rather than thinning mucus. Thinning of mucus would not typically contribute to airway obstruction.
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