A nurse is assessing a client who has acute kidney failure and is in a state of metabolic acidosis. The nurse should monitor for which of the following manifestations?

Bounding peripheral pulses

Hyperreflexia

Cool skin

Hypotension

Answer and Explanation

The Correct Answer is D

A) Bounding peripheral pulses: Metabolic acidosis typically does not cause bounding peripheral pulses. In metabolic acidosis, vasodilation might occur, but it usually leads to weaker, not bounding, pulses due to decreased cardiac output and blood pressure.

B) Hyperreflexia: Hyperreflexia is not commonly associated with metabolic acidosis. Instead, metabolic acidosis may cause symptoms like muscle weakness or fatigue due to the effect of acid-base imbalance on neuromuscular function.

C) Cool skin: While cool skin can sometimes be associated with poor perfusion in severe cases, it is not a direct manifestation of metabolic acidosis. Metabolic acidosis more commonly affects internal physiology rather than peripheral skin temperature directly.

D) Hypotension: Hypotension is a common manifestation of metabolic acidosis. The acidosis leads to vasodilation and decreased cardiac contractility, resulting in a drop in blood pressure. This is a critical sign for the nurse to monitor as it indicates the severity of the acid-base imbalance and its effect on the cardiovascular system.

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Correct Answer is A

Explanation

A) Measure the client's manifestations using an anxiety rating scale: This action is essential as the first step because it allows the nurse to accurately assess the severity of the client's anxiety. Understanding the level of anxiety helps in planning appropriate interventions and monitoring the effectiveness of any treatment provided. Accurate assessment is foundational in clinical decision making.

B) Initiate a referral to a local support group: While beneficial, referring the client to a support group should follow an initial assessment. Support groups can offer long-term benefits, but immediate needs and severity must be evaluated first.

C) Assist in finding alternative ways to cope: Helping the client develop coping strategies is an important intervention. However, before suggesting specific coping mechanisms, the nurse needs to understand the current level of anxiety and how it affects the client. This ensures that the coping strategies are appropriately tailored.

D) Administer an antianxiety medication: Administering medication can be crucial in managing severe anxiety, but this step should come after a thorough assessment. The nurse needs to determine if medication is necessary and what dosage might be appropriate, based on the anxiety rating scale and other assessment findings.

A. "I should limit my weightlifting to three times per week." B. "I can continue to horseback ride." C. "I will go walking with a friend around our neighborhood." D. "I will join my brother at his community aerobics class."

Correct Answer is C

Explanation

A) "I should limit my weightlifting to three times per week.": While weightlifting can be beneficial for bone health, it is generally recommended to engage in weight-bearing and resistance exercises more frequently than three times a week for optimal bone density. The frequency and type of weightlifting should be tailored to individual needs and safety considerations.

B) "I can continue to horseback ride.": Horseback riding, especially if not done carefully, poses a risk of falls and fractures, which can be dangerous for individuals with osteoporosis. Activities with a higher risk of injury should be avoided or approached with caution.

C) "I will go walking with a friend around our neighborhood.": Walking is a low-impact, weight-bearing exercise that promotes bone health and mobility without high risk. It is a suitable and recommended activity for individuals with osteoporosis to help maintain bone density and prevent falls.

D) "I will join my brother at his community aerobics class.": Aerobics classes may involve high-impact exercises and movements that could increase the risk of fractures or falls in individuals with osteoporosis. Low-impact, bone-strengthening activities are generally recommended instead.

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A nurse is assessing a client who has acute kidney failure and is in a state of metabolic acidosis. The nurse should monitor for which of the following manifestations?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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