The nurse is assessing a client who has a respiratory problem. Which clinical manifestation is most reflective of early hypoxia?
Confusion
Apnea
Cyanosis
Dysrhythmias
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This option correctly identifies therationale behind the nurse's instruction. Immunosuppressed clients have a weakened immune system, making them highly vulnerable to infections. Family members may carry microorganisms on their hands, clothes, or respiratory secretions that can potentially transmit infections to the client. Wearing gloves and a mask helps reduce the risk of introducing pathogens to the client.
A. This option suggests that the risk is related to hospital staff transmitting infections to family members. While this is a concern in healthcare settings, it is not directly related to the specific situation described where family members are visiting an immunosuppressed client in a protective environment.
B. This option implies that the hospital environment itself poses a risk of infection transmission to family members. While hospitals can harbor various pathogens, the primary concern in this scenario is the transmission of infections to the immunosuppressed client from outside sources, including family members.
D. This option suggests that the client could transmit infections to family members. While this is theoretically possible depending on the specific infectious agent and the client's condition, the primary concern in a protective environment is preventing infections from entering the client's environment and affecting their health.
Correct Answer is C
Explanation
C. A comprehensive approach ensures that all aspects of patient care, safety, and organizational processes are thoroughly reviewed and addressed according to TJC standards. This includes comprehensive assessments of patient needs, care plans, and quality improvement initiatives.
A. This term typically refers to the process of capturing images or videos at intervals over time. In the context of healthcare and TJC requirements, "time-lapsed" is not a standard term used by TJC.
B An emergency situation refers to a sudden and often critical medical situation requiring immediate attention and intervention. While TJC does have standards related to emergency preparedness and response in healthcare facilities, "emergency" is not specifically a type of TJC requirement in the context provided.
D. A focused approach refers to concentrating on specific areas or issues within healthcare organizations to address particular concerns or improvements. However, this is not specific about TJC.
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