A client is hyperventilating due to an acute psychologic stressor. The arterial blood gas results show that the client is in respiratory alkalosis. What is the nurse's initial intervention?
Administer an intravenous sedative
Assess the client for seizure activity
Assist the client in slowed breathing techniques
Check the client's blood pressure
The Correct Answer is C
C. Assisting the client in slowed breathing techniques is the most appropriate initial intervention for a client experiencing hyperventilation due to acute psychological stress. Slowed breathing techniques, such as pursed-lip breathing or diaphragmatic breathing, can help normalize respiratory rate and depth, thereby correcting the respiratory alkalosis. Encouraging the client to breathe slowly and deeply can help reduce the respiratory rate and restore a more balanced acid-base status.
A. Administering a sedative may not be the initial intervention for a client experiencing hyperventilation due to acute psychological stress. Sedatives can depress the respiratory drive further and may exacerbate respiratory alkalosis. Additionally, administering sedatives should be based on a comprehensive assessment and medical prescription, rather than as a first-line intervention for hyperventilation.
B. While hyperventilation can sometimes lead to symptoms resembling seizure activity (such as muscle twitching or numbness), assessing for seizure activity is not typically the initial intervention for respiratory alkalosis. In the context of acute psychological stress causing hyperventilation, addressing the hyperventilation itself is the priority.
D. While monitoring vital signs, including blood pressure, is important in assessing the client's overall condition, it is not the initial intervention specifically for addressing respiratory alkalosis due to hyperventilation. The priority in this situation is to address the hyperventilation itself through appropriate breathing techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
B. Increased mental acuity, or heightened alertness and cognitive function, is a characteristic response during the alarm stage of GAS. The body's stress response enhances mental focus and perception to help the individual recognize and respond to the stressor effectively.
C. During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the release of adrenaline (epinephrine) and norepinephrine. These hormones stimulate the kidneys to conserve water and sodium, leading to decreased urine output and increased urine retention. Therefore, increased urine retention is an expected physiologic manifestation in the alarm stage.
D. During the alarm stage, the sympathetic nervous system activation leads to bronchodilation, allowing for increased airflow to the lungs. This facilitates improved oxygenation of the blood and enhances the individual's ability to respond to the stressor by increasing oxygen delivery to tissues.
A. During the alarm stage of GAS, the body initiates the fight-or-flight response, which leads to the release of stress hormones such as cortisol and adrenaline. These hormones increase blood glucose levels through processes like glycogenolysis and gluconeogenesis to provide energy for the body to respond to the stressor. Therefore, decreased blood glucose is not an expected manifestation in the alarm stage.
E. Decreased pupil size: During the alarm stage of GAS, the sympathetic nervous system is activated, leading to the dilation of pupils (mydriasis). This allows for improved visual acuity and peripheral vision, enhancing the individual's ability to detect potential threats or stimuli in the environment.
Correct Answer is D
Explanation
D. This statement indicates an understanding of hospice care. Pain management is a crucial component of hospice care, and ensuring that patients have access to effective pain medication and symptom management is a priority. Hospice aims to maximize comfort and quality of life for patients, and providing pain relief is a fundamental aspect of this approach.
A. This statement suggests that the client may not fully understand the purpose of hospice care. Hospice care is generally provided to patients with a terminal illness who have a life expectancy of six months or less. The focus of hospice care is on comfort, quality of life, and symptom management rather than curative treatment. Planning for travel and activities like fishing may not align with the goals of hospice care.
B. This statement indicates a misunderstanding of hospice care. In hospice, patients are typically encouraged to have their loved ones and family members present and involved in their care, especially during the end-of-life period. Hospice care emphasizes emotional support, spiritual care, and the importance of family involvement during the dying process.
C. This statement may or may not indicate an understanding of hospice care, as it depends on the specific hospice setting and individual preferences. While some hospice programs may provide care in a hospital setting, many hospice services are delivered in the patient's home or in a hospice facility. The key aspect of hospice care is to provide comfort and support in a setting that best meets the patient's needs and wishes.
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