The nurse is caring for a client with respiratory failure. The client is lethargic and slow to follow commands. Current vital signs are: BP 88/52, pulse 132, respirations 8, and SPO2 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?
Endotracheal intubation with mechanical ventilation
Use of bi-level positive airway pressure ventilation (BiPAP)
Administration of 100% oxygen by mask
Insertion of an oral airway device to maintain the airway
The Correct Answer is A
A) Endotracheal intubation with mechanical ventilation:
Given the client’s lethargy, slow response to commands, and critical vital signs (e.g., low blood pressure of 88/52, high pulse rate of 132, respiratory rate of 8, and oxygen saturation of 84%), the client is in severe respiratory distress and may be at risk for respiratory failure. The low SpO2 of 84% on a 35% Venturi mask indicates that the client is not adequately oxygenating despite non-invasive oxygen support. In such situations, endotracheal intubation with mechanical ventilation is required to ensure adequate ventilation, oxygenation, and airway protection. This is the most appropriate intervention for a client in respiratory failure who is not responding to less invasive interventions like oxygen therapy or non-invasive ventilation.
B) Use of bi-level positive airway pressure ventilation (BiPAP):
BiPAP is a non-invasive ventilation option that is often used for patients with respiratory failure, particularly those with obstructive or central sleep apnea or those in the early stages of acute respiratory failure (e.g., chronic obstructive pulmonary disease exacerbations). However, given the client’s level of lethargy and deteriorating vital signs, BiPAP may not be sufficient. This client is showing signs of severe respiratory distress and requires more invasive management, such as endotracheal intubation and mechanical ventilation, to maintain an open airway and ensure adequate oxygenation and ventilation.
C) Administration of 100% oxygen by mask:
While oxygen administration is essential to manage respiratory failure, providing 100% oxygen via mask alone is unlikely to resolve the client's underlying issues, especially since the client’s oxygen saturation is critically low (84%) on 35% Venturi mask. Simply increasing the oxygen concentration will not be effective if the client’s respiratory failure is severe and the airway is compromised. More aggressive interventions, such as intubation, are necessary to manage the client’s airway and respiratory function appropriately.
D) Insertion of an oral airway device to maintain the airway:
An oral airway device is typically used for clients who are unconscious or semi-conscious to help keep the airway open. However, in this case, the client is lethargic but not fully unconscious, and the underlying issue is respiratory failure, not just a blocked airway. An oral airway device will not address the client’s inadequate ventilation or oxygenation and will not be sufficient to manage the client’s critical condition. The client requires intubation and mechanical ventilation to ensure adequate airway management and respiratory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Expect fluctuations of symptoms with temperature change: While symptom fluctuations may occur due to various factors, temperature changes are not a hallmark feature of Huntington's Disease (HD). HD is characterized by progressive motor, cognitive, and psychiatric symptoms, including involuntary movements (chorea), cognitive decline, and mood disturbances. Although other neurological conditions may show symptom fluctuations with temperature changes, this is not specific to HD.
B. New surgical techniques offer the best hope for a cure: There are currently no cures for Huntington's Disease, and while medical management can help manage symptoms (such as using medications for chorea or psychiatric symptoms), surgical techniques do not offer a cure for HD. The disease is progressive, and interventions typically focus on symptom management rather than cure. Families should be informed that while research is ongoing, a cure is not currently available.
C. Information about genetic testing: Huntington's Disease (HD) is a genetic disorder caused by a mutation in the HTT gene. It is inherited in an autosomal dominant pattern, meaning that a person with a parent who has HD has a 50% chance of inheriting the disease. Genetic testing is a critical part of the diagnosis process, and it can confirm the presence of the mutated gene before symptoms appear, which is important for family planning and early intervention. However, while genetic testing can provide information about whether an individual will develop the disease, it does not alter the course of the disease or provide a cure. It is essential to provide this information to clients and families, so they understand the role of genetic counseling and testing in managing the disease.
D. The disease process is intense but short in duration: Huntington's Disease is progressive and long-lasting. The disease usually begins in mid-adulthood (typically between ages 30-50), and the symptoms worsen over time. Individuals with HD may live for 15-20 years after symptom onset. The disease duration is long-term, not short, and it becomes increasingly debilitating as it progresses. The intensity of symptoms increases over time, and the disease is not characterized by a short duration.
Correct Answer is A
Explanation
A. Muscle rigidity and bradykinesia: Parkinson's disease (PD) is characterized by a combination of motor symptoms due to the degeneration of dopamine-producing neurons in the brain. The hallmark motor symptoms include muscle rigidity (stiffness of muscles, making movement difficult) and bradykinesia (slowness of movement). These symptoms are typically present early in the disease and can lead to difficulties with daily activities such as walking, speaking, and performing fine motor tasks. These two signs are primary indicators of Parkinson's disease.
B. Facial pain and ptosis: Facial pain and ptosis (drooping eyelids) are not typical symptoms of Parkinson's disease. PD can affect facial expression (resulting in a masked face), but it does not usually cause facial pain. Ptosis is more commonly seen in conditions like Horner's syndrome, myasthenia gravis, or as a side effect of medications, but it is not a hallmark symptom of Parkinson's disease.
C. Diarrhea and nausea: While gastrointestinal symptoms such as constipation can be seen in Parkinson's disease due to autonomic dysfunction and decreased gut motility, diarrhea and nausea are not typical primary symptoms. In fact, constipation is a more common issue in PD. Nausea could result from the use of medications like levodopa, but it is not a defining feature of the disease itself.
D. Ecchymosis and petechiae: Ecchymosis (bruising) and petechiae (small red or purple spots on the skin) are not characteristic of Parkinson's disease. These findings are more often associated with platelet disorders, bleeding disorders, or vascular conditions. While Parkinson's disease can involve complications like falls (which could lead to bruising), these are not direct symptoms of the disease itself. The primary symptoms involve motor and autonomic dysfunction.
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