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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E"]

Explanation

(A) Agency for Healthcare Research and Quality (AHRQ) website: The AHRQ is a reputable source of information for healthcare professionals. It provides evidence-based information on healthcare outcomes, quality, cost, use, and access.

(B) American Association of Critical Care Nurses (AACN) website: The AACN is a credible source of information for nurses working in critical care. It provides resources, education, and advocacy to ensure optimal care for critically ill patients.

(C) Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) website: AWHONN is a reputable organization that promotes the health of women and newborns. Its website provides evidence-based clinical practice guidelines and other resources for nurses.

(D) A pamphlet about hypoglycemia from the American Diabetes Association: The American Diabetes Association is a reputable source of information on diabetes. A pamphlet from this organization about hypoglycemia would be based on the latest research and would be a credible source of information.

(E) Cumulative Index of Nursing and Allied Health Literature (CINAHL) website: CINAHL is a comprehensive source of full-text for nursing & allied health journals, providing full text for more than 610 journals indexed in CINAHL. This is a highly respected research tool for nurses and allied health professionals.

A. Encourage the client to increase participation in community social activities B. Prepare the client to begin highly active antiretroviral therapy (HAART) C. Promote client weight gain of one to two pounds per week D. Provide routine analgesia to minimize episodes of breakthrough pain

Correct Answer is D

Explanation

(A) Encourage the client to increase participation in community social activities: While social activities can be beneficial for mental health, a client at the end of life may not have the physical strength or energy to participate in community social activities. Moreover, due to the compromised immune system in HIV, exposure to large groups could increase the risk of infections.

(B) Prepare the client to begin highly active antiretroviral therapy (HAART): HAART is typically initiated in the early stages of HIV infection to slow the progression of the disease. In a client who has had HIV for 10 years and is at the end of life, the focus would likely be on palliative care and symptom management rather than starting aggressive therapy.

(c) Promote client weight gain of one to two pounds per week: Weight gain might not be a realistic goal for a client at the end of life. Instead, maintaining a balanced diet to prevent malnutrition and managing symptoms like nausea and loss of appetite would be more appropriate.

(D) Provide routine analgesia to minimize episodes of breakthrough pain: This is the most appropriate intervention. Pain management is a critical aspect of end-of-life care. Providing routine analgesia can help ensure the client’s comfort and improve their quality of life. Breakthrough pain can be very distressing for the client, and managing it effectively can significantly enhance their well-being.

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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?

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