What does the nurse identify as INDIRECT cause of acute respiratory distress syndrome (ARDS) SELECT ALL THAT APPLY

Pneumonia

Drowning

Aspiration

Sepsis

Blood Transfusion

Answer and Explanation

Correct Answer : D,E

A) Pneumonia: Pneumonia is a direct cause of ARDS, as it involves direct inflammation and infection of the lung tissue, leading to impaired oxygen exchange and damage to the alveolar-capillary membrane. It results in fluid accumulation in the lungs, which is a key characteristic of ARDS.

B) Drowning: Drowning is another direct cause of ARDS. It involves the aspiration of water into the lungs, which directly damages lung tissue, causing pulmonary edema and impaired oxygenation.

C) Aspiration: Aspiration of food, liquid, or vomit into the lungs is also a direct cause of ARDS. The aspirated material can lead to chemical pneumonia, bacterial infection, and inflammation of the lungs, which in turn causes ARDS.

D) Sepsis: Sepsis is an indirect cause of ARDS. It can lead to widespread inflammation throughout the body, including the lungs, through the release of inflammatory mediators (cytokines, interleukins, etc.). These systemic inflammatory responses can increase capillary permeability in the lungs, causing fluid to leak into the alveoli, which leads to ARDS.

E) Blood Transfusion: Blood transfusion, particularly when associated with transfusion-related acute lung injury (TRALI), is an indirect cause of ARDS. TRALI is a serious complication that can result from receiving blood products, where the transfused blood causes an immune response leading to pulmonary damage. It indirectly triggers inflammation and fluid buildup in the lungs, contributing to ARDS.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Assess lung sounds and respiratory rate at least every 2 hours:
In a patient with Myasthenia Gravis (MG) who has undergone thymectomy, monitoring respiratory status is critical. MG is a neuromuscular disorder that can lead to respiratory muscle weakness, which may be exacerbated post-operatively. Assessing lung sounds and respiratory rate at least every 2 hours is crucial to detect early signs of respiratory compromise, including hypoventilation or atelectasis.

B) Assess and document pain level once every shift:
While pain assessment is important, especially after a thymectomy, this action alone does not directly address the immediate issue of ineffective breathing patterns. In patients with MG, respiratory complications are a priority concern. Pain management should be part of the overall plan of care, but it is secondary to monitoring respiratory function in the acute post-operative period. Pain can affect respiratory effort, but it should be managed in the context of more pressing issues like airway and breathing assessment.

C) Maintain sequential compression device (SCD's) while in bed:
While SCDs are important in preventing deep vein thrombosis (DVT) in patients who are immobile, they are not the most appropriate intervention for a client with ineffective breathing patterns. The primary concern in a post-thymectomy patient with MG is respiratory function.

D) Elevate the head of the bed ten degrees:
While elevating the head of the bed can help with comfort and potentially improve ventilation in some patients, it is not the most specific or effective intervention for managing ineffective breathing patterns in a patient with MG. For optimal respiratory function, it is typically more beneficial to elevate the head of the bed to a higher degree (e.g., 30-45 degrees) to enhance lung expansion, rather than just 10 degrees.

A. Glascow Coma Scale B. NIH Stroke Scale C. Romberg Test D. Mini Mental Status Exam

Correct Answer is A

Explanation

A) Glasgow Coma Scale:
The Glasgow Coma Scale (GCS) is a standardized neurological assessment tool used to assess a patient's level of consciousness based on three criteria: eye opening, verbal response, and motor response. Each of these categories is scored, and the total score helps to determine the depth of the patient's consciousness. The GCS is commonly used to monitor changes in a patient's neurological status, especially after trauma, stroke, or other conditions that may impair brain function.

B) NIH Stroke Scale:
The NIH Stroke Scale (NIHSS) is used to assess the severity of stroke symptoms and includes measures such as facial droop, arm and leg motor function, speech, and language abilities. It is used specifically to evaluate stroke symptoms and is not designed for the rapid assessment of general consciousness like the Glasgow Coma Scale.

C) Romberg Test:
The Romberg Test is a test of balance that is performed by having the patient stand with their feet together, eyes closed, and observing for any swaying or loss of balance. It is used to evaluate proprioception and cerebellar function, not to assess the level of consciousness.

D) Mini Mental Status Exam:
The Mini-Mental Status Exam (MMSE) is a brief cognitive screening tool that assesses aspects of cognitive function such as orientation, attention, memory, language, and visuospatial skills. While the MMSE can provide insight into cognitive function, it does not focus on the specific assessment of consciousness level (eye opening, verbal response, motor response) as the GCS does.

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What does the nurse identify as INDIRECT cause of acute respiratory distress syndrome (ARDS) SELECT ALL THAT APPLY

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with Myasthenia Gravis (MG) who is post op thymectomy. The client problem is Ineffective Breathing Pattern, Which action would the nurse include in the plan of care?

Correct Answer is A

Explanation

The nurse easily and quickly assesses changes in level of consciousness (eye opening, verbal responses motor response) using which neurological exams?

Correct Answer is A

Explanation

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