A nurse is caring for a client with an opioid overdose. The nurse should identify the client is at risk for which acid-base imbalance?
Metabolic acidosis
Respiratory acidosis
Respiratory alkalosis
Metabolic alkalosis
The Correct Answer is B
Choice A reason: Metabolic acidosis is characterized by a decrease in blood pH due to an accumulation of acids or a loss of bicarbonate. It can result from conditions such as diabetic ketoacidosis, renal failure, or severe diarrhea. However, it is not typically associated with opioid overdose. Opioid overdose primarily affects the respiratory system, leading to hypoventilation and respiratory acidosis.
Choice B reason: Respiratory acidosis occurs when there is an accumulation of carbon dioxide (CO2) in the blood due to hypoventilation. Opioid overdose depresses the central nervous system, leading to decreased respiratory rate and depth, which causes CO2 retention. This results in a decrease in blood pH, leading to respiratory acidosis. Symptoms may include confusion, lethargy, and shortness of breath.
Choice C reason: Respiratory alkalosis is characterized by a decrease in blood CO2 levels due to hyperventilation. It can occur in conditions such as anxiety, fever, or high altitude. Opioid overdose, however, causes hypoventilation rather than hyperventilation, making respiratory alkalosis an unlikely outcome.
Choice D reason: Metabolic alkalosis is characterized by an increase in blood pH due to an accumulation of bicarbonate or a loss of acids. It can result from conditions such as prolonged vomiting, diuretic use, or excessive bicarbonate intake. Opioid overdose does not typically lead to metabolic alkalosis. The primary concern with opioid overdose is respiratory depression and the resulting respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement reflects denial, which is a common initial reaction in the grief process. The client is not accepting the reality of their prognosis and believes the doctor is exaggerating. Denial serves as a defense mechanism to protect the individual from the emotional impact of the diagnosis. It is a way for the client to cope with the overwhelming news by rejecting its truth.
Choice B reason: This statement reflects anger, another stage in the grief process. The client is expressing disbelief and frustration towards the doctor’s competence. Anger often follows denial and is directed towards others as a way to cope with the emotional pain. It is not indicative of denial but rather a progression in the grieving process.
Choice C reason: This statement reflects acceptance of the physical symptoms and the reality of the client’s condition. The client acknowledges their lack of energy and the impact of the illness on their daily life. This is not a sign of denial but rather an acceptance of their current state.
Choice D reason: This statement reflects acceptance and gratitude towards the doctor. The client recognizes the efforts made by the healthcare team and accepts that their time is limited. This is a sign of acceptance, the final stage in the grief process, where the individual comes to terms with their situation.
Correct Answer is A
Explanation
Choice A Reason:
Cranial nerve V is the trigeminal nerve, which has both motor and sensory functions:Motor function: The nurse can assess this by asking the client to clench their teeth while palpating the masseter and temporalis muscles for strength.Sensory function: The nurse can assess this by lightly touching the client's face in different areas (forehead, cheeks, and jaw) with a cotton ball or sharp/dull object to check for sensation.
Choice B Reason:
Asking the client to identify scented aromas is a method used to assess cranial nerve I (Olfactory), not cranial nerve V. Cranial nerve V (Trigeminal) is assessed by testing facial sensation and motor functions such as chewing.
Choice C Reason:
Asking the client to read a Snellen chart is a method used to assess cranial nerve II (Optic), which is responsible for vision. This method does not assess cranial nerve V
Choice D Reason:
Asking the client to raise his eyebrows is a method used to assess cranial nerve VII (Facial), which controls facial expressions. This method is not used to assess cranial nerve V.
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