A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?
Anxiety over illness
Increased metabolic demands
Decreased drive to breathe
Infection destroying lung tissues
The Correct Answer is B
A. While anxiety may contribute to hyperventilation, in the context of a febrile child, the primary factor is usually metabolic.
B. Increased metabolic demands due to fever can elevate the body’s oxygen requirements, prompting hyperventilation as a compensatory mechanism.
C. Decreased drive to breathe would not lead to hyperventilation; rather, it might result in hypoventilation or respiratory distress.
D. Infection destroying lung tissues would typically lead to respiratory distress or failure, not directly cause hyperventilation without the context of increased metabolic needs.
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Correct Answer is A
Explanation
A. Hyperkalemia can lead to dangerous cardiac arrhythmias and other heart-related complications due to its effect on the electrical conduction system of the heart, making cardiac assessment the priority.
B. While neurological assessment is important in various conditions, it is secondary to assessing cardiac status in hyperkalemia.
C. Gastrointestinal symptoms can occur with hyperkalemia, but they do not pose an immediate life-threatening risk like cardiac issues do.
D. Respiratory assessment is essential in many contexts, but the immediate threat of hyperkalemia lies in its impact on heart function, making cardiac assessment the most critical.
Correct Answer is B
Explanation
A. Atelectasis is prevented primarily through deep breathing exercises and respiratory interventions, not passive ROM.
B. Passive ROM and splinting help prevent joint contractures by maintaining joint mobility and alignment, so the absence of contractures indicates successful prevention.
C. Pressure ulcers are avoided through regular repositioning and skin care rather than passive ROM alone.
D. Renal calculi are primarily prevented through hydration and diet, not passive ROM or splinting.