A 20-year-old male is in acute pain with restlessness and anxiety. An arterial blood gas reveals decreased CO2 levels. Which of the following does the nurse suspect is the most likely cause?
Hyperventilation
Nephrolithiasis
Acute fracture
Urinary tract infection
The Correct Answer is A
Choice A reason: Hyperventilation causes decreased CO2 levels (respiratory alkalosis) due to rapid breathing from pain, anxiety, or restlessness. This matches the patient’s symptoms and blood gas results, making it the correct cause.
Choice B reason: Nephrolithiasis causes pain but doesn’t typically lead to hyperventilation or low CO2. Respiratory alkalosis from hyperventilation better explains the findings, so this is incorrect for the cause.
Choice C reason: Acute fracture causes pain but not necessarily hyperventilation or low CO2. Anxiety-driven hyperventilation is more likely to cause respiratory alkalosis, so this is incorrect for the primary cause.
Choice D reason: Urinary tract infection may cause discomfort but not low CO2 or hyperventilation. Anxiety and pain causing hyperventilation align with the blood gas, so this is incorrect.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Retching is the involuntary attempt to vomit, involving abdominal muscle contractions without expelling stomach contents. The patient is actively expelling contents, which defines vomiting, not just the effort of retching, making this an incorrect term for documentation.
Choice B reason: Expectorate refers to coughing up and spitting out mucus or sputum from the respiratory tract. The patient is expelling stomach contents, not respiratory secretions, making expectorate an incorrect term for this gastrointestinal event.
Choice C reason: Regurgitation is the passive return of undigested food or liquid from the stomach or esophagus, often without force. The forceful expulsion of stomach contents described indicates vomiting, not regurgitation, making this an incorrect documentation term.
Choice D reason: Vomiting is the forceful expulsion of stomach contents through the mouth, driven by coordinated abdominal and diaphragmatic contractions. The patient’s active expulsion into a basin matches this definition, making vomiting the correct term for documentation.
Correct Answer is C
Explanation
Choice A reason: Release of inflammatory mediators drives inflammation, not angiogenesis. Pathological angiogenesis is excessive or abnormal vessel growth, often in diseases like cancer, so this is incorrect for the term.
Choice B reason: New vessel formation in response to injury is physiological angiogenesis, not pathological. Pathological angiogenesis involves abnormal, excessive growth, so this is incorrect for the described process.
Choice C reason: Pathological angiogenesis is excessive or abnormal blood vessel growth, seen in conditions like tumors or retinopathy. This matches the definition, making it the correct choice for the term.
Choice D reason: Inhibition of vessel formation is anti-angiogenic, not pathological angiogenesis. Excessive vessel growth defines the pathological state, so this is incorrect for the term.
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