The nurse is caring for a client who suffered a stroke 3 days ago and is assessing the client's state of arousal.
The nurse knows that the part of the body responsible for a person being alert or aroused is the

Choice A rationale

Asking "How loud is his snoring?" is subjective and difficult for the spouse to quantify accurately. While loudness can be a factor, it doesn't directly address potential underlying medical conditions like obstructive sleep apnea.

Choice B rationale

Determining the frequency of awakenings due to snoring provides some information about the impact on the spouse's sleep but doesn't offer specific details about the nature of the snoring itself or potential pauses in breathing.

Choice C rationale

Asking "Is there silence after snoring which then is followed with a snort?" directly inquires about a pattern indicative of obstructive sleep apnea. Apneic episodes involve cessation of breathing (silence), followed by a gasp or snort as the airway reopens.

Choice D rationale

Knowing the duration of snoring each night provides a general overview but doesn't offer specific details about the characteristics of the snoring, such as pauses in breathing or gasping, which are crucial for identifying potential sleep disorders. .

Choice A rationale

Hypokalemia, a deficiency of potassium in the blood (normal range: 3.5-5.0 mEq/L), typically leads to metabolic alkalosis due to intracellular hydrogen ion shifts. While respiratory and metabolic acid-base balances are interconnected, hypokalemia itself does not directly cause the retention of carbon dioxide, which is the hallmark of respiratory acidosis.

Choice B rationale

A high fever increases the metabolic rate, leading to increased oxygen consumption and carbon dioxide production. However, the body usually compensates for this by increasing the respiratory rate to expel the excess carbon dioxide. Therefore, while fever affects gas exchange, it is more likely to cause respiratory alkalosis due to hyperventilation, not acidosis.

Choice C rationale

Extreme anxiety can lead to hyperventilation, causing an excessive exhalation of carbon dioxide and a subsequent decrease in the partial pressure of carbon dioxide in the arterial blood (PaCO2). This results in respiratory alkalosis, not respiratory acidosis, where the PaCO2 is elevated (normal range: 35-45 mmHg).

Choice D rationale

Sedative overdose depresses the central nervous system, including the respiratory center in the brainstem. This depression leads to a decrease in both the rate and depth of breathing (hypoventilation). Inadequate ventilation causes the retention of carbon dioxide, leading to an increase in PaCO2 and a decrease in blood pH (normal range: 7.35-7.45), resulting in respiratory acidosis.