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Patient Data

Exhibits

What finding(s) are cues for a respiratory problem? Select all that apply.

Sitting upright

Tightness in the chest

Medication compliance

Respirations of 28 breaths/minute

Restlessness

Dyspnea

Pulse oxygenation of 85%

Answer and Explanation

Correct Answer : A,B,D,E,F,G

A.   Patients with respiratory distress often prefer to sit upright or in a tripod position to ease breathing by allowing maximal lung expansion. Sitting upright helps relieve pressure on the diaphragm and allows better air exchange in the lungs.
B.   Chest tightness is a common symptom of various respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), or pneumonia. It can result from bronchoconstriction, inflammation, or accumulation of mucus in the airways, leading to difficulty breathing.
D.   An increased respiratory rate (tachypnea) may indicate respiratory distress or difficulty breathing. Tachypnea is a compensatory mechanism to increase oxygen intake or remove carbon dioxide from the body when lung function is compromised.
E.   Restlessness can be a cue for a respiratory problem. Patients experiencing respiratory distress may exhibit restlessness due to hypoxia (low oxygen levels), discomfort, or anxiety related to difficulty breathing.
F.   Dyspnea, or shortness of breath, is a significant cue for a respiratory problem. It is a common symptom of various respiratory conditions, including asthma, COPD, pneumonia, and pulmonary embolism. Dyspnea may range from mild to severe and can significantly impact the patient's quality of life and functional status.
G.   A pulse oxygenation level of 85% indicates hypoxemia (low blood oxygen levels) and is a significant cue for a respiratory problem. Hypoxemia can result from various respiratory conditions or inadequate ventilation and may lead to tissue hypoxia and organ dysfunction if left untreated.
C. Medication compliance is not directly indicative of a respiratory problem. However, it may be relevant to managing respiratory conditions if the patient requires medications such as bronchodilators or corticosteroids to control symptoms or prevent exacerbations.
H. While an elevated heart rate (tachycardia) can be associated with respiratory distress, it is not specific to respiratory problems and may occur in response to other stressors or medical conditions.
I. Body mass index (BMI) is a measure of body fat based on height and weight and is not directly indicative of a respiratory problem. However, obesity is a risk factor for respiratory conditions such as obstructive sleep apnea and obesity hypoventilation syndrome.

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Correct Answer is B

Explanation

B. Lactulose works by acidifying the colonic contents, which promotes the conversion of ammonia (NH3) to ammonium (NH4+). Ammonium is less readily absorbed from the colon into the bloodstream, reducing systemic ammonia levels. This action helps alleviate the neurotoxic effects of ammonia on the brain, thereby improving neurological symptoms associated with hepatic encephalopathy.
A. Lactulose is required in clients with hepatic encephalopathy to excrete ammonia lowering its levels in blood. Holding the lactulose dose is inappropriate as the client’s ammonia levels are still high
C. Rehydrating the clients to replace lost fluids in the loose stools is important but does not address
the client’s elevated ammonia levels which may be exacerbating the client’s encephalopathy.
D. Reporting the number of diarrhea stools to the healthcare provider is important for ongoing assessment and management of the client's condition. However, it does not address the clients high ammonia levels.

A. Meningococcal meningitis. B. Cerebrovascular accident (CVA). C. Intracerebral hemorrhage. D. Rocky mountain spotted fever.

Correct Answer is A

Explanation

A. Meningococcal meningitis is a bacterial infection of the meninges (the protective membranes covering the brain and spinal cord) caused by the bacterium Neisseria meningitidis. It is characterized by symptoms such as severe headache, fever, nuchal rigidity (stiff neck), and a petechial rash on the skin. The petechial rash is a distinguishing feature of meningococcal meningitis and is caused by bleeding into the skin due to disseminated intravascular coagulation (DIC) associated with the infection.
B. A cerebrovascular accident, commonly known as a stroke, occurs when blood flow to a part of the brain is interrupted, leading to tissue damage and neurological deficits. While a stroke can cause symptoms such as headache and neurological deficits, it typically does not present with fever, nuchal rigidity, or a petechial rash.

C. Intracerebral hemorrhage is bleeding within the brain tissue, often due to the rupture of a blood vessel. It can cause symptoms such as headache, neurological deficits, and alterations in consciousness, but it typically does not present with fever, nuchal rigidity, or a petechial rash.
D. Rocky mountain spotted fever (RMSF) is a bacterial infection caused by the bacterium. While RMSF can present with fever and rash, it typically does not present with nuchal rigidity, and the petechial rash associated with RMSF tends to start on the extremities rather than the arms and legs.

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Patient Data Exhibits What finding(s) are cues for a respiratory problem? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client presents with the onset of a severe headache, fever, nuchal rigidity, and a petechial rash on arms and legs. The nurse recognizes the client is exhibiting symptoms of which condition?

Correct Answer is A

Explanation

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Patient Data

Exhibits

What finding(s) are cues for a respiratory problem? Select all that apply.