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.)

Choice A reason: Narrowed pulse pressure is not a specific manifestation of pneumonia in the older adult client. Pulse pressure is the difference between the systolic and diastolic blood pressure readings. A normal pulse pressure is about 40 mm Hg, and a narrowed pulse pressure is less than 25 mm Hg. A narrowed pulse pressure can indicate various conditions, such as heart failure, shock, or aortic stenosis, but it is not a sign of pneumonia.

Choice B reason: Night sweats are not a common manifestation of pneumonia in the older adult client. Night sweats are episodes of excessive sweating during sleep that can soak the bedding or clothing. Night sweats can have many causes, such as menopause, infections, medications, or cancer, but they are not typically associated with pneumonia.

Choice C reason: Bradycardia is not a usual manifestation of pneumonia in the older adult client. Bradycardia is a slow heart rate, defined as less than 60 beats per minute. Bradycardia can be normal in some people, such as athletes or those who are very fit, or it can be a sign of a problem with the heart's electrical system. Pneumonia does not cause bradycardia, but it can cause tachycardia, which is a fast heart rate, due to the increased oxygen demand and inflammation.

Choice D reason: Confusion is a frequent manifestation of pneumonia in the older adult client. Confusion is a state of impaired awareness, orientation, memory, or judgment. Confusion can occur in older adults with pneumonia due to several factors, such as hypoxia, dehydration, electrolyte imbalance, fever, or infection. Confusion can also increase the risk of complications, such as aspiration, falls, or delirium. Therefore, the nurse should monitor the mental status of the older adult client with pneumonia and report any changes to the provider..

Choice A reason: Flexing the upper and extending the lower extremities in response to the painful stimulus is not an expected response for a client who has a traumatic head injury. This is a sign of decorticate posturing, which indicates damage to the cerebral hemispheres or the internal capsule. Decorticate posturing is a type of abnormal flexion that involves the abduction of the arms, internal rotation of the shoulders, flexion of the wrists, and extension of the legs.

Choice B reason: Pushing the painful stimulus away is not an expected response for a client who has a traumatic head injury. This is a sign of normal motor function, which indicates that the client can localize and withdraw from the painful stimulus. This is the highest level of motor response on the Glasgow Coma Scale (GCS), which is a neurological scoring system used to assess conscious level after head injury.

Choice C reason: Extending the body toward the painful stimulus is an expected response for a client who has a traumatic head injury. This is a sign of decerebrate posturing, which indicates damage to the brainstem or midbrain. Decerebrate posturing is a type of abnormal extension that involves the abduction of the arms, external rotation of the shoulders, extension of the wrists, and extension of the legs.

Choice D reason: Showing no reaction to the painful stimulus is not an expected response for a client who has a traumatic head injury. This is a sign of flaccid paralysis, which indicates damage to the spinal cord or peripheral nerves. Flaccid paralysis is a type of complete loss of muscle tone and reflexes that involves the absence of any voluntary or involuntary movements.