The nurse is caring for a patient who presents in the emergency room with respiratory acidosis.
After assessing the patient, which of the patient's findings is the probable cause of respiratory acidosis?
Hypokalemia.
High Fever.
Extreme Anxiety.
Sedative Overdose.
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Impaired Skin Integrity involves damage to the epidermal and/or dermal layers of the skin. While excessive fluid loss can indirectly affect skin turgor and increase the risk of breakdown over time, the primary and immediate physiological consequence of increased urinary output due to a diuretic is a potential reduction in overall fluid volume within the body, not a direct impairment of skin integrity.
Choice B rationale
Impaired Urinary Elimination describes difficulties in controlling or completely emptying the bladder. A diuretic, by its mechanism of action, increases urine production and thus promotes urinary elimination. While the *pattern* of elimination may change (increased frequency, urgency), the fundamental issue is not an impairment of the elimination process itself but rather an *increase* in it.
Choice C rationale
Urinary Retention is the inability to empty the bladder completely. A diuretic works to increase urine output, directly counteracting the physiological process of urinary retention. Therefore, this nursing diagnosis would be inappropriate for a client experiencing increased urinary output due to diuretic use.
Choice D rationale
Risk for Deficient Fluid Volume is a nursing diagnosis that identifies a vulnerability to a decrease in intravascular, interstitial, and/or intracellular fluid, which may compromise health. A diuretic increases urinary output, leading to a greater loss of fluid from the body. Without adequate fluid intake to compensate for this increased loss, the client is at a significant risk of developing a fluid volume deficit.
Correct Answer is B
Explanation
Choice A rationale
"If I could just live long enough to attend my son's graduation, I would be satisfied" represents bargaining, the third stage of grief according to Kübler-Ross. In this stage, the individual attempts to negotiate or make deals to postpone the inevitable.
Choice B rationale
"I believe there has been a mistake. I should have gotten a second opinion" is a classic example of denial, the first stage of grief. Denial is a defense mechanism where the individual refuses to accept the reality of the situation, often seeking alternative explanations or contradicting information.
Choice C rationale
"I know I am depressed and I can't stop crying" exemplifies depression, the fourth stage of grief. This stage is characterized by feelings of sadness, hopelessness, and withdrawal as the reality of the loss begins to sink in.
Choice D rationale
"I am very angry and mad. This is not fair" represents anger, the second stage of grief. In this stage, the individual expresses frustration, resentment, and outrage at the situation and may direct these feelings towards others. .
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