Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials "911" because Anne is unconscious, has depressed ventilation (shallow and slow respirations), rapid heart rate, and is bleeding from both ears.
Which primary acid-base imbalance is Anne at risk for if medical attention is not provided?
Respiratory Alkalosis.
Metabolic Alkalosis.
Respiratory Acidosis.
Metabolic Acidosis.
The Correct Answer is C
Choice A rationale
Respiratory alkalosis occurs due to hyperventilation, leading to excessive carbon dioxide expulsion. This reduces the partial pressure of carbon dioxide ($PaCO_2$), increasing the pH. Anne's depressed ventilation indicates hypoventilation, not hyperventilation, which would cause an accumulation of $CO_2$ rather than its expulsion. Therefore, respiratory alkalosis is not the primary imbalance she faces.
Choice B rationale
Metabolic alkalosis arises from an excess of bicarbonate ($HCO_3^-$) or a loss of hydrogen ions ($H^+$), typically from vomiting or diuretics. This increases the pH. Anne's symptoms of depressed ventilation and head trauma do not directly point to a primary metabolic issue causing $HCO_3^-$ retention or $H^+$ loss; her immediate risk is respiratory compromise.
Choice C rationale
Respiratory acidosis develops when the lungs cannot adequately remove carbon dioxide ($CO_2$), leading to its accumulation in the blood. This accumulation increases carbonic acid, which lowers the pH. Anne's depressed ventilation (shallow and slow respirations) directly impairs $CO_2$ excretion, causing $CO_2$ retention and a decrease in blood pH, thus predisposing her to respiratory acidosis. Normal $PaCO_2$ range is 35-45 mmHg.
Choice D rationale
Metabolic acidosis results from an accumulation of non-carbonic acids or a loss of bicarbonate ($HCO_3^-$). This lowers the pH. While head trauma can sometimes lead to metabolic derangements, Anne's immediate and primary physiological compromise is depressed ventilation, which directly affects $CO_2$ elimination and respiratory acid-base balance rather than metabolic acid accumulation or bicarbonate loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Positioning the patient sitting on the edge of the bed, leaning on a pillow on the bedside table, is the optimal position for a thoracentesis. This position maximizes the intercostal spaces, allowing for easier access to the pleural cavity while keeping the diaphragm in a lowered position. This widens the spaces between the ribs, facilitating needle insertion and minimizing the risk of injury to surrounding structures like the lungs or diaphragm.
Choice B rationale
Placing the patient in a prone position is contraindicated for a thoracentesis. This position would make accessing the posterior pleural space extremely difficult and unsafe, increasing the risk of accidental organ puncture. It offers no anatomical advantage for the procedure and significantly impedes proper visualization and access to the typical insertion site.
Choice C rationale
Lying supine with arms folded across the chest is not an appropriate position for a thoracentesis. This position would flatten the intercostal spaces, making needle insertion more challenging and increasing the risk of lung puncture. It does not provide optimal access to the pleural cavity for fluid drainage and limits respiratory excursion.
Choice D rationale
Stating no particular positioning is required for a thoracentesis is incorrect and potentially dangerous. Proper positioning is critical for patient safety and procedural success, as it optimizes access to the pleural space, minimizes risks, and enhances patient comfort during the procedure. Incorrect positioning can lead to complications.
Correct Answer is B
Explanation
Choice A rationale
Placing an NG tube could potentially worsen a basilar skull fracture or cause further injury by penetrating the cranial vault if the cribriform plate is compromised. This intervention is contraindicated when clear fluid, possibly cerebrospinal fluid, is draining from the nose, indicating a potential breach in the dura mater.
Choice B rationale
Testing the clear fluid for the presence of glucose is a critical diagnostic step. Cerebrospinal fluid (CSF) contains glucose, whereas nasal secretions do not. A positive glucose test strongly indicates a CSF leak, which is a significant complication of facial trauma that requires specific management to prevent intracranial infection. Normal CSF glucose ranges from 40 to 70 mg/dL.
Choice C rationale
Encouraging coughing and deep breathing would increase intrathoracic and intracranial pressure, which could exacerbate a CSF leak and potentially introduce pathogens into the intracranial space. This action should be avoided as it poses a risk for further neurological complications such as meningitis.
Choice D rationale
Placing a mustache dressing on the patient might absorb the drainage but does not address the underlying issue of a potential CSF leak. Furthermore, applying pressure or occluding the nares could impede the free flow of CSF, potentially leading to a build-up of pressure and increasing the risk of retrograde infection into the central nervous system.
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