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. A patient with hypercapnia requires monitoring, but wearing an oxygen mask indicates some level of intervention is in place.
B. A patient with a chest tube should never ambulate with the chest tube unclamped, as this can lead to a collapsed lung and respiratory distress; thus, this patient should be prioritized.
C. While a patient with thick secretions may need suctioning, this is not as critical as ensuring the safety of a patient with an unclamped chest tube.
D. A patient with a new tracheostomy requires monitoring, but the presence of the obturator indicates readiness for emergencies; this does not take priority over the safety of the patient with the chest tube.
Correct Answer is B
Explanation
A. The definition of spirituality does not typically include concepts of fire or giving life; this option does not accurately capture the essence of spirituality.
B. Awareness of one's inner self encompasses the essence of spirituality, focusing on personal beliefs, values, and the search for meaning, which is widely recognized in health care.
C. Spirituality is often considered equally essential to physical needs, especially in holistic approaches to health and well-being, making this statement misleading.
D. Spirituality can have a significant impact on health, influencing coping mechanisms and overall well-being; therefore, labeling it as having a minor effect is not accurate.