A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?
Circumoral numbness and tingling
Muscle flaccidity
Decreased level of consciousness
Cool, clammy skin
The Correct Answer is C
Acute respiratory acidosis occurs when there is inadequate excretion of carbon dioxide due to respiratory dysfunction, leading to an increase in carbon dioxide levels (hypercapnia) and subsequent acidosis (decrease in pH).
Manifestations of acute respiratory acidosis include:
A. Circumoral numbness and tingling - This is associated with respiratory alkalosis, not acidosis. B. Muscle flaccidity - This is more commonly seen in hyperkalemia or conditions affecting neuromuscular transmission. C. Decreased level of consciousness - This is a key manifestation of acute respiratory acidosis due to the effects of hypercapnia on the central nervous system. D. Cool, clammy skin - This is not typically associated with acute respiratory acidosis; instead, it might be seen in shock or hypoperfusion states.
Therefore, the nurse should expect to find a decreased level of consciousness in a client experiencing acute respiratory acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
(A) Lean back in the chair: Leaning back in the chair can be perceived as a relaxed posture, but it might also convey disinterest or detachment in the conversation. Active listening involves being engaged and showing interest in what the client is saying.
(B) Use intermittent eye contact: This is the most appropriate answer. Maintaining eye contact is an important part of active listening as it shows that the nurse is focused and interested in what the client is saying. However, constant eye contact can be intimidating or uncomfortable for some clients, so intermittent eye contact is often more appropriate.
(c) Have a pen and paper: Having a pen and paper can be useful for note-taking, but it is not a direct action of active listening. It’s important to maintain focus on the client during the conversation, and excessive note-taking can be distracting.
(D) Sit side-by-side with the client: While sitting side-by-side with the client can create a more relaxed and equal atmosphere, it is not a direct action of active listening. The nurse should face the client and maintain appropriate eye contact to show engagement and interest.
Correct Answer is B
Explanation
A. Increase in postoperative pain: Preoperative teaching typically includes information about pain management strategies, which should help to reduce, not increase, postoperative pain.
B. Reduced postoperative anxiety: This is correct. One of the key benefits of preoperative education is reduced anxiety. By understanding what to expect before, during, and after surgery, patients are often less anxious about the procedure.
C. Reduced postoperative respiratory function: Preoperative teaching usually includes instructions on deep breathing and coughing exercises to help prevent respiratory complications after surgery. Therefore, it should improve, not reduce, postoperative respiratory function.
D. Increased length of postoperative care in the health care facility: Preoperative education has been shown to reduce the length of hospital stay. By better understanding their surgery and postoperative care, patients are often able to recover more quickly and leave the hospital sooner
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