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 A
Explanation
Choice A Reason:
MS hug is appropriate. The "MS hug" is a colloquial term used to describe a sensation of tightness, pressure, or squeezing around the torso or chest area experienced by some individuals with multiple sclerosis (MS). It is caused by spasms or contractions of the intercostal muscles (muscles between the ribs) or the diaphragm due to lesions in the spinal cord disrupting nerve signals. This sensation can be uncomfortable or painful for the individual.
Choice B Reason:
Lhermitte's sign is inappropriate. Lhermitte's sign is a common symptom experienced by individuals with MS but it presents differently. It is characterized by an electric shock-like sensation that radiates down the spine and into the limbs, typically triggered by flexing the neck forward. It is caused by damage to the spinal cord's myelin sheath, leading to abnormal nerve signal transmission.
Choice C Reason:
Paroxysmal spasms is inappropriate. Paroxysmal spasms are sudden, involuntary muscle contractions or jerking movements that can occur in various parts of the body. While spasms are common in MS, they are not specifically associated with the sensation of tightness around the torso as described in the scenario.
Choice D Reason:
Trigeminal neuralgia is inappropriate. Trigeminal neuralgia is a condition characterized by sudden, severe facial pain often described as stabbing or electric shock-like. It is caused by irritation or damage to the trigeminal nerve, which is responsible for facial sensation. While individuals with MS may experience trigeminal neuralgia, it typically does not present with a tightening feeling around the torso.
Correct Answer is C
Explanation
Choice A Reason:
Placing the client on clear liquids might not be appropriate in this situation because absent bowel sounds in the lower abdominal quadrants could indicate a more serious gastrointestinal issue such as ileus or bowel obstruction. Clear liquids may exacerbate these conditions and are not sufficient to address the underlying problem. Therefore, this option is not recommended until the cause of absent bowel sounds is identified and addressed.
Choice B Reason:
Performing a hemoccult blood test is not directly relevant to the situation described. Hemoccult tests are used to detect occult (hidden) blood in stool, which can be indicative of gastrointestinal bleeding. While it's important to assess for gastrointestinal bleeding in some cases, absent bowel sounds in the lower abdominal quadrants suggest a more immediate concern related to gastrointestinal motility rather than bleeding. Therefore, this option is not the most appropriate action at this time.
Choice C Reason:
Inserting a nasogastric tube is the most appropriate action in this scenario. Absent bowel sounds in a client with a spinal cord injury can indicate neurogenic bowel dysfunction, which may lead to abdominal distention and discomfort. Inserting a nasogastric tube can help decompress the stomach and intestines, reducing the risk of complications such as aspiration and providing relief from discomfort. It can also help manage gastrointestinal complications until further assessment and interventions can be implemented.
Choice D Reason:
Forcing the intake of fluids may not be appropriate without further assessment and could potentially worsen the client's condition if there is an underlying gastrointestinal issue leading to absent bowel sounds. Additionally, forcing fluids may not address the potential issue of gastrointestinal bleeding.
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