14. Which nursing diagnosis reflects the basic rationale for symptoms in a client with acute respiratory distress syndrome (ARDS)?
14. Which nursing diagnosis reflects the basic rationale for symptoms in a client with acute respiratory distress syndrome (ARDS)?
. Ineffective breathing pattern.
. High risk for infection.
. Impaired gas exchange.
. Activity intolerance.
Test-Taking Tip
When all options appear relevant, choose the one that addresses the key term (i.e., "basic rationale"). Answers 1, 2, and 4 are more the result rather than the cause of the symptoms. Choose the broader answer (Answer 3) that encompasses another related answer (Answer 1).
Content Area: Adult Health, Respiratory; Integrated Process: Nursing Process, Analysis; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Pathophysiology
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Answer 1 is incorrect because, although there are symptoms of ineffective breathing pattern, it is the sequela from the impaired gas exchange. Answer 2 is incorrect because an infection is a risk or precipitating factor for ARDS. The question asks for the rationale for the impaired gas exchange. Answer 3 is correct because ARDS affects the arterial-alveolar capillary membrane gas exchange. The basic pathophysiology in ARDS is alveolar capillary damage, decreased surfactant, and the resultant noncardiogenic pulmonary edema. As a result, carbon dioxide cannot be eliminated, oxygen cannot be absorbed, and severe hypoxemia and acidosis result. Answer 4 is incorrect because, although activity intolerance is present, it is due to the hypoxia from protein accumulation in the alveoli. The RN must monitor the arterial blood gases to assess levels of hypercapnea and hypoxemia.