A client is hyperventilating due to an acute psychologic stressor. The arterial blood gas results show that the client is in respiratory alkalosis. What is the nurse's initial intervention?
Administer an intravenous sedative
Assess the client for seizure activity
Assist the client in slowed breathing techniques
Check the client's blood pressure
The Correct Answer is C
C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.
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Related Questions
Correct Answer is A
Explanation
A. This approach involves providing medication education to the client as each medication is administered. While this ensures that the client receives information about each medication in a timely manner, it may not allow for comprehensive education or adequate time for the client to ask questions or clarify information. Additionally, the client may feel overwhelmed by receiving information about multiple medications at once.
B. Incorporating medication education into another activity, such as assisting the client with his bath, can be an efficient use of time. However, it may not provide an optimal environment for focused learning and discussion. The client may be distracted or uncomfortable during the bath, limiting their ability to absorb and retain information effectively.
C. This approach involves providing medication education to the client after discharge via a follow-up phone call. While this allows for more time and flexibility in providing education, it may not address the client's immediate needs or questions prior to discharge. Additionally, the client may have already started taking the medications by the time of the follow-up call, potentially leading to missed opportunities for clarification or adjustment of the medication regimen.
D. Providing written instructions for the client to read at home is an efficient way to ensure that the client has access to information about their medications. This allows the client to review the information at their own pace and refer back to it as needed. However, written instructions alone may not be sufficient for addressing all aspects of medication education, such as potential side effects, drug interactions, or administration techniques.
Correct Answer is C
Explanation
C. Full compensation typically occurs within 2 to 3 days (approximately 72 hours) after the onset of an acid-base disturbance. During full compensation, the primary acid-base disorder (e.g., respiratory acidosis or alkalosis, metabolic acidosis or alkalosis) is still present, but the compensatory mechanisms have effectively brought the pH, pCO2, and bicarbonate (pHCO3) levels back towards normal range.
A. Full compensation occurs when both the primary disorder (respiratory or metabolic) and the compensatory mechanism (renal or respiratory) are functioning to return the pH towards normal. In this option, while the pO2 is within the normal range, the pH, pCO2, and bicarbonate (pHCO3) are all abnormal, indicating an ongoing imbalance.
B. Full compensation occurs when all components of the ABG are within or approaching normal range, indicating that the body's compensatory mechanisms have effectively counteracted the primary acid- base disturbance. In this option, the bicarbonate (pHCO3) is mentioned as starting to change, indicating incomplete compensation.
D. While the pH is within the normal range, both the pCO2 and pO2 are abnormal, indicating a primary respiratory disturbance. In the case of full compensation, the pH, pCO2, and bicarbonate (pHCO3) levels would all be within or approaching normal range, indicating that the compensatory mechanisms have effectively counteracted the primary acid-base disturbance.
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