The nurse is assessing a client with suspected metabolic acidosis. Which finding would be consistent with this diagnosis?
Kussmaul respirations
Muscle spasms
Paresthesia in fingers
Tinnitus
The Correct Answer is A
a. Kussmaul respirations: Metabolic acidosis leads to an accumulation of acids in the body, resulting in compensatory hyperventilation to try to decrease the levels of carbon dioxide and increase pH. Kussmaul respirations are deep, rapid, and labored breathing patterns characteristic of this compensation mechanism.
b. Muscle spasms: While muscle spasms can occur in various conditions, they are not specific to metabolic acidosis. Other factors, such as electrolyte imbalances or dehydration, may cause muscle spasms.
c. Paresthesia in fingers: Paresthesia (tingling or numbness) in the fingers can occur due to metabolic acidosis. Acidosis affects nerve function, leading to abnormal sensations in the extremities. It is not specific to metabolic acidosis.
d. Tinnitus: Tinnitus is not typically associated with metabolic acidosis. It is more commonly associated with conditions such as ototoxicity, Meniere's disease, or vascular disorders affecting the inner ear.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rheumatic fever: This inflammatory condition can affect various parts of the heart, including the mitral and aortic valves. Repeated episodes of rheumatic fever can lead to scarring and thickening of the heart valves, eventually causing stenosis (narrowing) of the mitral or aortic valve.
b. Endocarditis: This infection of the heart lining or valves can damage the structures, but it's not as directly linked to both mitral and aortic stenosis as rheumatic fever.
c. Marfan’s syndrome:Marfan syndrome is a genetic disorder that can affect connective tissue throughout the body, including the heart valves. It is commonly associated with aortic root dilatation and aortic regurgitation rather than aortic stenosis. While aortic valve involvement can occur in Marfan syndrome, it is not typically associated with mitral stenosis.
d. Female gender: While gender differences exist in the prevalence of certain cardiovascular conditions, such as rheumatic heart disease affecting more females than males, gender alone is not a significant risk factor for the development of either mitral or aortic stenosis.
Correct Answer is B
Explanation
a. Review I&O (Intake and Output): While reviewing intake and output is an essential component of assessing fluid status in heart failure, it is not the immediate priority in this scenario. The client's presentation with dyspnea and crackles suggests acute respiratory distress, which requires immediate assessment and intervention to address potential hypoxemia.
b. Check pulse oximetry: In a client presenting with elevated blood pressure, dyspnea, and bilateral crackles throughout lung fields, the priority intervention is to assess oxygenation status. Checking pulse oximetry provides immediate information about the client's oxygen saturation levels, which is crucial for determining the severity of respiratory distress and guiding subsequent interventions. Hypoxemia is a common complication in heart failure exacerbations and can worsen symptoms such as dyspnea and respiratory distress.
c. Administer digoxin: Digoxin is a medication commonly used in the management of heart failure to improve cardiac output and reduce heart rate. However, it is not the priority intervention in this scenario. Assessing oxygenation status and addressing respiratory distress take precedence over administering medications.
d. Obtain 12-lead ECG: While obtaining a 12-lead ECG is important for assessing cardiac rhythm and identifying any potential cardiac abnormalities, it is not the immediate priority in this scenario. The client's presentation with acute respiratory distress warrants immediate assessment of oxygenation status to guide appropriate interventions.
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