A nurse is reviewing the arterial blood gas values for a client. The nurse should recognize that the values indicate which of the following acid-base imbalances?

The values are:

• pH: 7.56
• PaCO2: 55 mmHg
• HCO3: 33 mEq/L

Normal ranges:

• pH: 7.35-7.45
• PaCO2: 35-45 mmHg
• HCO3: 22-28 mEq/L

Choice A Reason:

Ask close-ended questions is incorrect. Close-ended questions typically elicit short, specific responses such as “yes” or “no.” While they can be useful in certain situations, they do not provide enough information to thoroughly assess a client’s mental status. Open-ended questions allow the client to express themselves more fully, providing the nurse with better insight into their cognitive function.

Choice B Reason:

Ask open-ended questions is correct. Open-ended questions encourage the client to elaborate on their thoughts and feelings, which can reveal more about their mental status. This type of questioning helps the nurse assess the client’s orientation, memory, and thought processes more effectively.

Choice C Reason:

Use directive questions is incorrect. Directive questions are more structured and guide the client towards specific answers. While they can be useful for obtaining specific information, they do not allow for a comprehensive assessment of the client’s mental status.

Choice D Reason:

Use reflective questions is incorrect. Reflective questions are used to encourage the client to think more deeply about their responses and feelings. While they can be helpful in therapeutic settings, they are not the most effective for an initial assessment of mental status.

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.