Which of the following findings should indicate to the nurse the client is experiencing hypoxia? The client’s heart rate increases. PREVIOUS The client is diaphoretic. The client’s blood pressure decreases. Z W S X e d ? r E f % 5 t V Dil 6 g y b & 7 h u n Time Elapsed: 00:04:00 Pause Remaining: 08:20:00 J i 9 m k O ) ?
The Correct Answer and Explanation is :
The correct answer to the question is: The client is diaphoretic.
Explanation:
Diaphoresis, or excessive sweating, can be a clinical indicator of hypoxia, especially in the context of tracheostomy care where the airway is directly affected. Hypoxia occurs when the body or a region of the body is deprived of adequate oxygen supply at the tissue level. It can develop rapidly with airway compromises, such as those potentially occurring during tracheostomy suctioning.
When a client experiences hypoxia, the body responds by activating the sympathetic nervous system. This response leads to several physiological reactions:
- Increased Heart Rate: The heart beats faster in an attempt to deliver more oxygenated blood to the tissues.
- Elevated Blood Pressure: Initially, blood pressure may rise as part of the sympathetic nervous system activation.
- Diaphoresis: Sweating is a sympathetic nervous system response, often exacerbated by anxiety or distress associated with hypoxia. The body sweats in an effort to cool down, despite this not directly alleviating hypoxia.
Among the options provided:
- An increase in heart rate is a common response to hypoxia but is a nonspecific sign that can occur with various other conditions such as fever, pain, or anxiety.
- A decrease in blood pressure is more indicative of other complications like shock or severe hypoxia affecting cardiac output, which is a later and more severe manifestation.
The presence of diaphoresis specifically in the setting of tracheostomy suctioning is particularly indicative of hypoxia because it represents a direct systemic response to decreased oxygen levels, as the body tries to manage its reduced capacity to oxygenate the blood.
In summary, while an increased heart rate and changes in blood pressure are important clinical signs, the onset of diaphoresis during tracheostomy care is a more direct and immediate indicator of hypoxia, signaling that the nurse needs to reassess the airway management and oxygen delivery to the client.
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