A nurse is caring for a client in the emergency department (ED) who has high anxiety and shallow respirations at a rate of 30/min. Which of the following acid-base disturbances is the client most likely experiencing?
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
The Correct Answer is B
A. Respiratory acidosis occurs due to hypoventilation, resulting in carbon dioxide retention. This condition is characterized by slow, shallow breathing and confusion, which is not consistent with the client's rapid respiratory rate of 30/min.
B. Respiratory alkalosis is typically caused by hyperventilation, where excessive breathing leads to a decrease in carbon dioxide levels. The client's symptoms of high anxiety and rapid, shallow respirations are indicative of hyperventilation, making respiratory alkalosis the most likely diagnosis.
C. Metabolic acidosis is characterized by deep, rapid breathing (Kussmaul respirations) as the body attempts to expel excess acid. The client's shallow respirations are inconsistent with the breathing pattern seen in metabolic acidosis.
D. Metabolic alkalosis usually presents with symptoms such as dizziness and tingling, often with compensatory slow respirations. The rapid respiratory rate in this case does not suggest metabolic alkalosis, making this option unlikely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Repeating the same question over and over: This behavior might indicate confusion or lack of understanding but is not a typical anticipated outcome of education. Effective education should lead to better understanding rather than repeated questions.
B. Awareness of COPD manifestations: An anticipated outcome of education for a client with COPD is increased awareness of their condition and its manifestations. This knowledge helps the client manage their symptoms and recognize exacerbations early.
C. Anxiety and restlessness: While some anxiety might be present, effective education aims to reduce anxiety by providing information and strategies for managing COPD. The goal is to increase confidence and knowledge, which can help mitigate anxiety.
D. Motivation and engagement of the client: While motivation and engagement are positive outcomes, they are not the primary focus of initial educational interventions. The primary goal is to ensure that the client is aware of their condition and understands how to manage it effectively.
Correct Answer is D
Explanation
A. Respiratory alkalosis: This condition is characterized by a high pH and low PaCO2. In this case, the pH is low and PaCO2 is high, indicating that respiratory alkalosis is not present.
B. Metabolic acidosis: Metabolic acidosis is indicated by a low pH and a low bicarbonate level. Here, the pH is low but the bicarbonate level is normal, so metabolic acidosis is not the primary diagnosis.
C. Metabolic alkalosis: This condition involves a high pH and elevated bicarbonate. The pH in this case is low, so metabolic alkalosis is not present.
D. Respiratory acidosis: Respiratory acidosis is indicated by a low pH and high PaCO2. The client's pH is 7.22 (acidic) and PaCO2 is 68 mm Hg (elevated), which is consistent with respiratory acidosis. The bicarbonate level is normal, indicating that there is no significant metabolic compensation yet.
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