What signs and symptoms indicate hypoxia? Select all that apply.
Alert and oriented
Cyanosis
Anxiety and restlessness
Oxygen saturation 96%
Capillary refill 5 seconds
Correct Answer : B,C,E
A) Alert and oriented: Being alert and oriented typically indicates adequate oxygenation, not hypoxia. Patients experiencing hypoxia are more likely to show signs of confusion or altered mental status rather than clarity.
B) Cyanosis: Cyanosis is a classic sign of hypoxia, presenting as a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood. This is a significant indicator of inadequate oxygenation.
C) Anxiety and restlessness: These symptoms are common responses to hypoxia as the body attempts to compensate for insufficient oxygen. Patients may feel anxious or restless as they struggle to breathe or feel a sense of impending doom.
D) Oxygen saturation 96%: An oxygen saturation level of 96% is generally considered normal and indicates adequate oxygenation. Therefore, this finding does not suggest hypoxia.
E) Capillary refill 5 seconds: A prolonged capillary refill time can indicate poor perfusion and potential hypoxia. Inadequate blood flow can lead to reduced oxygen delivery to tissues, making this a relevant sign of hypoxia
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Correct Answer is C
Explanation
A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.
B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.
C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.
D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.
Correct Answer is C
Explanation
A) Third left ICS: The third left intercostal space (ICS) is typically associated with the auscultation of the pulmonic valve rather than the tricuspid valve. While it is in the vicinity of the heart, it is not the correct location for assessing the tricuspid area.
B) Second right ICS: The second right intercostal space is where the aortic valve is best heard. This location is important for assessing blood flow through the aorta, but it is not relevant for the tricuspid valve auscultation.
C) Fourth left ICS: The tricuspid valve is best auscultated at the fourth left intercostal space along the left sternal border. This area allows for optimal listening to the sounds produced by the tricuspid valve, providing important information about right heart function.
D) Second left ICS: The second left intercostal space is the auscultation point for the pulmonic valve, not the tricuspid valve. While this area is critical for assessing the heart, it does not correspond to the location for the tricuspid valve.