Edited Text
A nurse is auditing a client. During the assessment, the nurse notes the client has multiple cavities, chipped, and missing teeth. The client reports having difficulty eating. Which diet should the nurse recommend the primary health care provider to order for this client?

Choice A Reason:

Restlessness is often one of the earliest signs of hypoxia. When the body experiences low oxygen levels, the brain is one of the first organs to be affected. This can lead to symptoms such as anxiety, agitation, and restlessness as the brain struggles to function properly without adequate oxygen. These symptoms occur because the body is trying to compensate for the lack of oxygen by increasing respiratory and heart rates, which can make a person feel uneasy or restless.

Choice B Reason:

Cyanosis refers to a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. While cyanosis is a significant indicator of hypoxia, it is typically a later sign. By the time cyanosis is visible, hypoxia has usually been present for some time, and oxygen levels have been critically low. Therefore, it is not the earliest clinical manifestation of hypoxia.

Choice C Reason:

Apnea is the absence of breathing. This is a severe and late sign of hypoxia. When a person stops breathing, it indicates that the body has been deprived of oxygen for an extended period, leading to critical conditions. Apnea is a medical emergency and requires immediate intervention, but it is not an early sign of hypoxia.

Choice D Reason:

Bradycardia is a slower than normal heart rate. Like apnea, bradycardia is a late sign of hypoxia. Initially, the body responds to low oxygen levels by increasing the heart rate (tachycardia) to pump more oxygenated blood to tissues. Bradycardia occurs when the body can no longer compensate, and the heart rate slows down, indicating severe hypoxia and impending failure of the cardiovascular system.

Choice A Reason:

“Records that the client sees the procedure as necessary” is incorrect. The nurse’s role in signing the consent form is not to document the client’s perception of the necessity of the procedure. This responsibility typically falls to the healthcare provider who explains the procedure and its necessity to the client.

Choice B Reason:

“Determines the client does not have a mental illness” is incorrect. While assessing the client’s mental status is part of the overall care, the nurse’s signature on the consent form does not specifically indicate this. The nurse’s role is to witness the client’s signature and ensure they are giving informed consent.

Choice C Reason:

“Assists that the nurse has explained the risks and benefits of the procedure” is incorrect. It is the responsibility of the healthcare provider performing the procedure to explain the risks and benefits. The nurse may reinforce this information but does not primarily provide it.

Choice D Reason:

“Confirms the client is competent to provide consent” is correct. The nurse’s signature on the consent form indicates that the nurse has witnessed the client signing the form and has verified that the client is competent to provide informed consent. This includes ensuring the client understands the information provided and is making the decision voluntarily.