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 B

Explanation

B. Such an assessment helps in determining the level of assistance the client will need and ensures the safety of both the client and the nurse.

A. Helping the client to sit at the edge of the bed allows them to acclimate to being upright, assess their readiness to stand, and ensures their safety before attempting to walk. However, it is not the priority.

C. After assisting the client to a sitting position at the edge of the bed and assessing their readiness, the nurse can proceed to help the client into a standing position. However, it is not the priority.

D. This option may be necessary if the client requires two-person assistance due to their condition, mobility status, or safety concerns. However, asking for assistance typically comes after assessing the client's readiness and ensuring they are positioned correctly for ambulation.

A. develop a nurse-client relationship. B. enhance well-being. C. assess skin integrity. D. stimulate circulation. E. moisturize the skin.

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Bathing can indeed foster a nurse-client relationship. It provides an opportunity for interaction and communication between the nurse and the client, promoting trust and rapport.

B Bathing can contribute to the client's overall sense of well-being. It promotes comfort, relaxation, and a feeling of cleanliness, which are important aspects of holistic care.

C. Bathing allows the nurse to visually assess the client's skin integrity. During the process, the nurse can identify any changes in skin color, presence of lesions, wounds, or other abnormalities that may require further assessment or intervention.

D. Bathing, particularly when accompanied by gentle massage or movement of limbs, can stimulate circulation. This helps improve blood flow to tissues, aiding in wound healing and reducing the risk of complications such as pressure ulcers.

E. Depending on the type of bath products used (e.g., moisturizing soap or bath oils), bathing can help moisturize the skin. This is especially beneficial for clients with dry skin or conditions that predispose them to skin dryness.

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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 will be assisting the client to walk. What should the nurse do first?

Correct Answer is B

Explanation

The nurse recognizes that the Rationale(s) for giving a client a bath is (are) to: (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","D","E"]

Explanation

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