Which clinical manifestation is most reflective of an early response to hypoxia?
Restlessness
Cyanosis
Apnea
Bradycardia
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Keep the drainage system below the level of the client’s chest at all times is correct. This measure ensures that gravity assists in the drainage of air and fluid from the pleural space, preventing backflow into the chest cavity. Keeping the drainage system below chest level maintains the negative pressure needed for effective drainage.
Choice B Reason:
Clamp the chest tube prior to transferring the client to a wheelchair is incorrect. Clamping the chest tube can lead to a buildup of air or fluid in the pleural space, potentially causing a tension pneumothorax. The chest tube should remain unclamped to allow continuous drainage.
Choice C Reason:
Empty the collection chamber prior to transport is incorrect. While it is important to monitor and manage the drainage, emptying the collection chamber is not necessary before transport. The focus should be on maintaining the integrity and function of the drainage system.
Choice D Reason:
Disconnect the chest tube from the drainage system during transport is incorrect. Disconnecting the chest tube can lead to a loss of the negative pressure system, resulting in potential complications such as pneumothorax. The chest tube should remain connected to ensure continuous drainage and maintain the negative pressure.
Correct Answer is D
Explanation
Choice A Reason:
Defamation of character is incorrect. Defamation of character involves making false statements about someone that damage their reputation. This can be in the form of slander (spoken) or libel (written). Applying restraints without proper justification does not fall under defamation of character.
Choice B Reason:
Invasion of privacy is incorrect. Invasion of privacy involves intruding into someone’s personal life without consent. This can include unauthorized access to personal information or spaces. Applying restraints without proper justification is not an invasion of privacy.
Choice C Reason:
Slander is incorrect. Slander is a form of defamation that involves making false spoken statements that damage someone’s reputation. Applying restraints without proper justification does not involve making false statements.
Choice D Reason:
False imprisonment is correct. False imprisonment involves restraining a person without legal justification or their consent. In a healthcare setting, applying restraints without proper justification or following legal and ethical guidelines constitutes false imprisonment and violates the client’s rights.
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