The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

Confusion

Apnea

Cyanosis

Dysrhythmias

Answer and Explanation

The Correct Answer is A

A. Confusion can be an early sign of hypoxia, especially when oxygen delivery to the brain is compromised. Inadequate oxygenation can affect cognitive function and mental status, leading to confusion. This occurs because the brain is highly sensitive to changes in oxygen levels.

B. Apnea refers to the absence of breathing. While severe hypoxia can lead to respiratory arrest and apnea, it is not typically an early manifestation of hypoxia. Early hypoxia is characterized by attempts to increase ventilation to compensate for decreased oxygen levels, rather than complete cessation of breathing.

C. Cyanosis occurs when there is a bluish discoloration of the skin and mucous membranes due to deoxygenated hemoglobin in the blood. Cyanosis is a late sign of hypoxia and usually indicates significant oxygen deprivation. It is not typically seen in early hypoxia stages.

DDysrhythmias (irregular heart rhythms) can occur as a result of hypoxia, especially if the heart muscle is not receiving enough oxygen. However, dysrhythmias are generally considered a later manifestation of hypoxia, as the heart attempts to compensate for decreased oxygen delivery.

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Correct Answer is D

Explanation

D. This problem indicates that the client is not receiving adequate nutrition to meet metabolic needs, which can lead to malnutrition and compromised healing. Addressing imbalanced nutrition is crucial for maintaining health and supporting recovery.

A. This problem refers to disturbances in sexual function or satisfaction. While important to address, it is not typically considered a high priority compared to other physiological or safety-related issues unless it B This problem indicates the potential for the client to experience loneliness or social disconnection, which can impact mental and emotional well-being. While addressing social isolation is important for holistic care, it may not be as urgent as issues related to physical health or safety.

C This problem indicates the inability to endure physical activities or exercise due to insufficient physiological or psychological energy. Activity intolerance can be a significant concern post-operatively or in clients with chronic conditions, as it can affect recovery and overall functional ability.

A. Client found on floor, appeared to have fallen out of bed as a result of getting tangled in bed linens. B. Client fell out of bed, but did push the call button for assistance. C. Recorder responded to client's call light, upon entering the room, found client on floor D. Client became tangled in the bed linens, then called for assistance after falling out of bed.

Correct Answer is C

Explanation

C. This entry is factual and avoids assumptions about how the client ended up on the floor, focusing instead on the sequence of events as discovered by the recorder. It is important to avoid speculation and to document only what is directly observed or verifiable.

A. This option provides a clear description of the situation: the client was found on the floor, and it attributes the fall to getting tangled in bed linens. However, it includes an assumption of how the client fell.

B. This option indicates that the client fell out of bed and did push the call button for assistance. While it acknowledges the fall and the use of the call button, it doesn't specify who found the client on the floor or the circumstances surrounding the discovery.

D. This option suggests that the client called for assistance after falling out of bed due to being tangled in bed linens. It mentions the sequence of events (tangled in bed linens first, then called for assistance), but it doesn't specify who found the client on the floor or the action taken thereafter.

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The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?

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Naxlex Comprehensive Predictor Exams

The nurse is prioritizing a client's problem list. Which of the following problems should receive the highest priority?

Correct Answer is D

Explanation

When responding to a call light, the nurse finds a client lying on the floor, with the bed linens around the legs. Which chart entry should the nurse document for this finding?

Correct Answer is C

Explanation

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