The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?
Elevated blood pressure
Increased pulse rate
Cyanosis
Restlessness
The Correct Answer is C
A. Elevated blood pressure may occur with various conditions but is not a specific late sign of hypoxia.
B. An increased pulse rate can be an early compensatory response to hypoxia rather than a late sign.
C. Cyanosis, which is a bluish discoloration of the skin and mucous membranes, is a classic late sign of hypoxia, indicating severe oxygen deprivation.
D. Restlessness may indicate early signs of hypoxia or anxiety rather than a late sign and can occur before cyanosis develops.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Readiness for enhanced urinary elimination" is classified as a health promotion diagnosis, indicating the patient’s desire to improve their health condition and adopt new health behaviors.
B. A risk diagnosis is used when there is a potential for problems to occur, not applicable in this scenario as the patient is actively seeking improvement.
C. A problem-focused diagnosis describes an existing problem that requires intervention; this situation reflects readiness for improvement, not an existing issue.
D. A collaborative problem involves potential complications that require both nursing and medical management; this case focuses on the patient's willingness to learn a self-management skill rather than managing a specific medical problem.
Correct Answer is D
Explanation
A. The belief tool typically involves assessing specific beliefs but does not encompass the broader scope of spiritual well-being.
B. The FICA assessment tool focuses on Faith, Importance, Community, and Address, but it is not characterized by a lengthy questionnaire.
C. The Hope scale assesses a patient's sense of hope but does not specifically address spirituality in depth.
D. The spiritual well-being scale includes multiple questions that explore various aspects of spirituality, including the relationship with God and life purpose, making it the most appropriate choice for this assessment.
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