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.
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Correct Answer is B
Explanation
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.
Correct Answer is C
Explanation
A. While metabolic acidosis is a potential concern for some diabetic conditions, avoiding acidic foods is not a common dietary guideline for managing diabetes.
B. Including dairy can contribute to calcium intake but does not directly impact diabetes management.
C. Staying hydrated is essential for overall health and helps regulate blood sugar levels, making it an appropriate dietary recommendation for this patient.
D. Since the patient does not require insulin, strict carbohydrate reduction may not be necessary, making this option less relevant.