The nurse is performing a complete bed bath for a comatose client. What action best communicates caring to this client?
Having another nurse assist to perform the bed bath
Making sure that daily hygiene was completed on time
Speaking in a calm voice and using gentle touch
Maintaining eye contact with the client throughout
The Correct Answer is C
A. Having another nurse assist to perform the bed bath: Assistance may be necessary for safety and efficiency, especially with immobile clients, but it does not inherently convey emotional presence or therapeutic communication. The focus is on task completion rather than directly expressing caring behaviors to the client.
B. Making sure that daily hygiene was completed on time: Timeliness reflects organization and adherence to routine care, but it does not address the interpersonal aspect of nursing. Completing hygiene on schedule ensures physical care needs are met but does not demonstrate compassion or emotional connection.
C. Speaking in a calm voice and using gentle touch: Even in a comatose state, patients may retain some level of sensory perception, particularly auditory and tactile awareness. Calm verbal communication and gentle touch promote dignity, reduce potential stress responses, and reflect holistic, patient-centered care that acknowledges the client’s humanity despite unconsciousness.
D. Maintaining eye contact with the client throughout: Eye contact is a valuable communication tool for conscious patients, but in a comatose client, it does not provide meaningful interaction. Since the client cannot visually engage, this action does not effectively convey caring compared to auditory and tactile approaches.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Metabolic acidosis: Metabolic acidosis is characterized by a decreased pH (<7.35) and a decreased bicarbonate (HCO₃⁻ <22 mEq/L) as the primary disturbance. In this scenario, although the pH is low (7.19), the bicarbonate level is within normal range (26.2 mEq/L), indicating that the acidosis is not metabolic in origin but rather due to another primary process.
B. Metabolic alkalosis: Metabolic alkalosis presents with an elevated pH (>7.45) and increased bicarbonate levels. The patient’s pH is significantly decreased, ruling out alkalosis. Additionally, the bicarbonate level is not elevated enough to suggest a primary metabolic alkalotic process.
C. Normal ABG results: Normal ABG values include a pH of 7.35–7.45, PaCO₂ of 35–45 mmHg, and HCO₃⁻ of 22–26 mEq/L. This patient’s pH is markedly acidotic and the PaCO₂ is significantly elevated at 65.8 mmHg, indicating an abnormal acid-base imbalance.
D. Respiratory acidosis: Respiratory acidosis is identified by a low pH and elevated PaCO₂ (>45 mmHg), indicating hypoventilation and carbon dioxide retention. The normal bicarbonate level suggests minimal or no metabolic compensation, indicating an acute or partially compensated state. Slightly decreased PaO₂ and oxygen saturation further support impaired gas exchange consistent with respiratory compromise.
Correct Answer is A
Explanation
A. Metabolic acidosis: The patient’s pH of 7.13 indicates acidemia, and the HCO3- is significantly decreased at 13.2 mEq/L, showing a primary metabolic derangement. The PaCO2 of 38.8 mmHg is within normal limits (35–45 mmHg), suggesting that respiratory compensation has not yet fully occurred. The base excess of -14.5 further supports a significant metabolic acid load. These findings are consistent with metabolic acidosis.
B. Respiratory acidosis: Respiratory acidosis is characterized by elevated PaCO2 (>45 mmHg) due to hypoventilation, which leads to a decreased pH. In this case, the patient’s PaCO2 is normal, indicating that CO2 retention is not the primary cause of acidemia. The primary disturbance is metabolic rather than respiratory.
C. Normal ABG results: Normal arterial blood gas values include pH 7.35–7.45, PaCO2 35–45 mmHg, HCO3- 22–28 mEq/L, and PaO2 80–100 mmHg. In this ABG, the pH is acidotic, HCO3- is low, and base excess is markedly negative, which clearly deviates from normal ranges, indicating a pathological process.
D. Respiratory alkalosis: Respiratory alkalosis is characterized by decreased PaCO2 (<35 mmHg) due to hyperventilation, resulting in an elevated pH. In this ABG, PaCO2 is normal and pH is low, which contradicts the pattern seen in respiratory alkalosis. The acidemia is therefore not caused by a respiratory mechanism.
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