nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)
Hypotension
Decreased level of consciousness
Severe dyspnea
Headache
Nausea
Correct Answer : B,C
Choice A reason: Hypotension is not a common manifestation of ARF. Hypotension is a low blood pressure, defined as less than 90/60 mm Hg. Hypotension can have many causes, such as dehydration, blood loss, heart problems, or medications. ARF does not directly cause hypotension, but it can lead to complications such as shock or organ failure, which can lower the blood pressure.
Choice B reason: Decreased level of consciousness is a frequent manifestation of ARF. Decreased level of consciousness is a state of impaired awareness, orientation, memory, or judgment. Decreased level of consciousness can occur in ARF due to several factors, such as hypoxia, hypercapnia, acidosis, or infection. The nurse should monitor the mental status of the client with ARF and report any changes to the provider.
Choice C reason: Severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective sensation of difficulty breathing or shortness of breath. Severe dyspnea can occur in ARF due to the reduced oxygen delivery or increased carbon dioxide retention in the blood. The nurse should assess the respiratory rate, rhythm, depth, and effort of the client with ARF and provide oxygen therapy as prescribed.
Choice D reason: Headache is not a typical manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can have many causes, such as stress, dehydration, sinusitis, or migraine. ARF does not directly cause headache, but it can cause increased intracranial pressure or cerebral edema, which can trigger headache.
Choice E reason: Nausea is not a usual manifestation of ARF. Nausea is a feeling of sickness or discomfort in the stomach that can lead to vomiting. Nausea can have many causes, such as food poisoning, motion sickness, pregnancy, or medications. ARF does not directly cause nausea, but it can cause gastrointestinal bleeding or hepatic encephalopathy, which can induce nausea.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "I will be able to tell how much oxygen I'm getting by looking at the flowmeter." This statement is correct because the flowmeter shows the amount of oxygen delivered in liters per minute. The client should check the flowmeter regularly and adjust it according to the prescription.
Choice B reason: "I should call my doctor if I find it harder to concentrate." This statement is correct because difficulty concentrating can be a sign of low oxygen levels or carbon dioxide retention. The client should monitor their symptoms and report any changes to their doctor.
Choice C reason: "I will wear synthetic clothing and woolen socks when using my oxygen." This statement is incorrect because synthetic clothing and woolen socks can create static electricity and increase the risk of fire when using oxygen. The client should wear cotton clothing and avoid materials that can cause sparks.
Choice D reason: "I will make sure my visitors smoke outside." This statement is correct because smoking near oxygen can cause a fire or explosion. The client should keep oxygen away from open flames, smoking materials, and heat sources.
Correct Answer is B
Explanation
Choice A reason: "My wife tries to get me to go to the grocery store, but I don't like to go out much." This statement indicates that the client is not adapting well, as they are avoiding social activities and isolating themselves. The client may have low self-esteem, depression, or anxiety.
Choice B reason: "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." This statement indicates that the client is adapting well, as they are using adaptive devices and practicing their skills. The client also expresses a positive attitude and a sense of improvement.
Choice C reason: "My greatest pleasure each day is having a few beers every day." This statement indicates that the client is not adapting well, as they are abusing alcohol and possibly selfmedicating. The client may have emotional distress, chronic pain, or addiction.
Choice D reason: "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier." This statement indicates that the client is not adapting well, as they are not using the available resources and opting for a less independent option. The client may have low motivation, poor selfcare, or learned helplessness.
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