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. Blood flow starts from the right atrium, moves into the right ventricle, then to the lungs, where it is oxygenated and returns to the left atrium, and then flows into the left ventricle before being pumped into the aorta.
B. This sequence incorrectly places the left atrium before the right ventricle, which is not the correct flow of blood.
C. This sequence starts incorrectly with the right ventricle, skipping the left atrium entirely after blood is oxygenated.
D. This option also incorrectly starts with the right ventricle and does not include the proper sequence of blood flow.
Correct Answer is D
Explanation
A. Sequential compression devices are used to prevent deep vein thrombosis and are not relevant for assessing orthostatic hypotension.
B. Elastic stockings are used to promote venous return and prevent edema, not for measuring blood pressure.
C. A thermometer measures body temperature and does not provide information on blood pressure or orthostatic changes.
D. A blood pressure cuff is essential for assessing orthostatic hypotension. The nurse will measure blood pressure while the patient is supine, sitting, and standing to determine any significant changes that occur with position changes.