A client experiencing respiratory acidosis as a result of COPD is likely to present with which of the following clinical signs? (Select all that apply)
Repeatedly asking "Where am I?"
Difficult to arouse
Barrel chest
Dysrhythmias
Rapid, shallow respirations
Correct Answer : A,B,D
A. Repeatedly asking "Where am I?": This can be a sign of confusion or disorientation due to the buildup of CO2 in respiratory acidosis. As CO2 accumulates in the blood, it can lead to impaired brain function, resulting in confusion or altered mental status.
B. Difficult to arouse: Respiratory acidosis leads to increased CO2 levels, which can depress the central nervous system, causing lethargy and difficulty arousing the patient. This is a common manifestation of respiratory acidosis, especially in severe cases.
C. Barrel chest: A barrel chest is a long-term, chronic structural change in the chest wall, commonly seen in individuals with advanced COPD. While a client with COPD will likely have a barrel chest, it is a chronic anatomical finding, not an acute clinical sign resulting from current respiratory acidosis.
D. Dysrhythmias: Elevated CO2 levels can affect the heart's electrical conduction system, leading to arrhythmias. This is a known complication of respiratory acidosis, particularly in COPD patients, as the body struggles to compensate for the acidotic state.
E. Rapid, shallow respirations: Rapid, shallow respirations are more typical of respiratory alkalosis, where the body is trying to expel CO2 quickly. In respiratory acidosis, the body may attempt to compensate by increasing the rate of breathing, but the respirations are typically deep and labored (Kussmaul's respirations), not shallow.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Renal: In respiratory acidosis, the kidneys compensate by retaining bicarbonate (HCO3-) and excreting hydrogen ions (H+), which helps to restore normal pH levels. This compensation process can take hours to days, as the renal system gradually works to balance the acid-base disturbance.
B. Endocrine: The endocrine system plays a role in regulating various body functions, but it is not responsible for compensating respiratory acidosis. While hormones like aldosterone affect fluid and electrolyte balance, they do not compensate for acid-base imbalances.
C. Respiratory: The respiratory system itself is the cause of respiratory acidosis due to inadequate ventilation and CO2 retention. The body cannot rely on the same system (respiratory) for compensation; compensation comes from the renal system instead.
D. Gastrointestinal: The gastrointestinal system does not directly compensate for respiratory acidosis. While it is involved in digestion and nutrient absorption, it does not play a significant role in regulating blood pH during acid-base imbalances.
Correct Answer is C
Explanation
A. Assess the patients for edema in extremities: While assessing for edema can be helpful in heart failure patients, it may not be the most effective method to monitor fluid volume status in patients at risk for dehydration, as edema may not be present in early dehydration.
B. Ask the patients to record their intake and output: Recording intake and output is important for monitoring fluid balance, but it is not as reliable as daily weight measurements. Patients may not be accurate in recording intake and output, especially in acute settings.
C. Weigh the patients every morning before breakfast: Weighing patients at the same time every day provides the most accurate and reliable measure of fluid volume status. A sudden weight gain or loss can indicate fluid retention in heart failure or dehydration, making this the most effective intervention for monitoring fluid status in both conditions.
D. Measure the patients' blood pressures every 4 hours: Blood pressure monitoring can provide some insight into fluid status, but it is not as directly indicative of fluid volume as daily weights. BP changes may not be as sensitive to small fluctuations in fluid volume.
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