The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?

Increased muscle tension

Altered sleep patterns

Increased peristalsis

Impaired immunity

Answer and Explanation

The Correct Answer is D

D. Impaired immunity is a serious complication of prolonged stress that can have significant implications for overall health and susceptibility to illness. Chronic stress has been linked to dysregulation of the immune system, leading to decreased immune function and increased susceptibility to infections, autoimmune disorders, and other illnesses. Impaired immunity can compromise the body's ability to fight off pathogens and may contribute to the development or exacerbation of various health conditions.
A. Increased muscle tension is a common physiological response to stress but it is not typically considered a serious complication. Prolonged muscle tension can lead to discomfort, headaches, and musculoskeletal issues, but it is not usually life-threatening or associated with severe complications.
B. Altered sleep patterns, such as insomnia or disrupted sleep, can be significant consequences of prolonged stress. Chronic sleep disturbances can negatively impact physical health, cognitive function, and emotional well-being. While altered sleep patterns can have serious implications for overall health and quality of life, they are not typically considered life-threatening in the short term.
C. Increased peristalsis refers to heightened movement of the gastrointestinal tract, which can result in symptoms such as diarrhea or gastrointestinal discomfort. While gastrointestinal disturbances are common manifestations of stress, they are generally not considered the most serious complication of prolonged stress. However, severe or persistent gastrointestinal symptoms may warrant medical evaluation and management.

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Correct Answer is A

Explanation

A. Positioning the primary IV solution bag higher than the piggyback medication bag creates a pressure gradient, allowing the primary solution to infuse first. Once the primary solution has finished, the secondary piggyback medication automatically starts infusing. This setup ensures that the primary solution is fully infused before the piggyback medication begins.
B. Placing the primary IV solution bag lower than the piggyback medication bag is not the standard practice. This setup would create a pressure gradient that could result in the piggyback medication infusing before the primary solution, which is not desirable. It could lead to incomplete infusion of the primary solution and compromise the effectiveness of the treatment.
C. Positioning the primary IV solution bag at the same height as the piggyback bag does not create a pressure gradient for sequential infusion. As a result, both solutions would flow at the same rate, and it would be challenging to control the order of infusion. This setup is not appropriate for administering IV antibiotics via piggyback because it does not ensure the proper sequence of infusion.
D. The height of the IV solution relative to the insertion site is essential for proper infusion and preventing complications such as infiltration or phlebitis. Ideally, the IV solution should be hung at a height that allows for a gentle flow of fluid into the vein without causing excessive pressure or backflow. Placing the IV solution lower than the insertion site helps facilitate gravity-assisted flow into the vein.

A. metabolic alkalosis. B. respiratory alkalosis. C. metabolic acidosis. D. respiratory acidosis.

Correct Answer is A

Explanation

A. Metabolic alkalosis is characterized by an elevation of the bicarbonate (HCO3) levels in the blood, leading to an increase in pH above the normal range (7.35-7.45). Antacid tablets typically contain compounds such as calcium carbonate, magnesium hydroxide, or aluminum hydroxide, which can neutralize stomach acid (hydrochloric acid). Chronic ingestion of large amounts of antacids, as in the case of this client taking approximately 15 tablets per day, can result in excessive bicarbonate intake, leading to metabolic alkalosis.
B. Respiratory alkalosis occurs when there is a decrease in carbon dioxide (CO2) levels in the blood, leading to an increase in pH above the normal range. Antacid tablets do not directly affect respiratory function or CO2 levels, so respiratory alkalosis is unlikely to occur as a result of antacid ingestion.
C. Metabolic acidosis is characterized by a decrease in bicarbonate (HCO3) levels in the blood, leading to a decrease in pH below the normal range. In the context of antacid ingestion, metabolic acidosis is less likely to occur. However, if the antacids contain compounds that are absorbed systemically and excreted by the kidneys (such as aluminum-containing antacids), they may lead to renal dysfunction or electrolyte imbalances, which could potentially contribute to metabolic acidosis.
D. Respiratory acidosis occurs when there is an increase in carbon dioxide (CO2) levels in the blood, leading to a decrease in pH below the normal range. Antacid tablets do not directly affect respiratory function or CO2 levels, so respiratory acidosis is unlikely to occur as a result of antacid ingestion.

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The nurse is assessing a client who has been experiencing prolonged stress. For which most serious complication should the nurse monitor the client?

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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