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 D
Explanation
D. In metabolic acidosis, the pH would be low (acidemic) and the HCO3 level would be below the normal range. In the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, indicating metabolic acidosis.
A. In respiratory alkalosis, the pH would be elevated (alkalotic) and the PaCO2 would be below the normal range (hypocapnia). However, in the provided ABG results, the pH is low (acidemia) rather than high, ruling out respiratory alkalosis.
B. In respiratory acidosis, the pH would be low (acidemic) and the PaCO2 would be above the normal range (hypercapnia). However, in the provided ABG results, the PaCO2 is within the normal range, ruling out respiratory acidosis.
C. In metabolic alkalosis, the pH would be elevated (alkalotic) and the HCO3 level would be above the normal range. However, in the provided ABG results, the pH is low (acidemic) and the HCO3 level is below the normal range, ruling out metabolic alkalosis.
Correct Answer is D
Explanation
D. Consuming alcoholic beverages, especially close to bedtime, can disrupt sleep patterns and exacerbate insomnia. While alcohol may initially have a sedative effect and induce drowsiness, it can lead to fragmented and poor-quality sleep later in the night, resulting in worsened insomnia symptoms. Therefore, this statement indicates a need for further education by the nurse regarding the negative impact of alcohol consumption on sleep and the importance of avoiding alcohol before bedtime to improve sleep quality.
A. Keeping the bedroom cool (around 65 degrees Fahrenheit) is generally recommended for promoting sleep because a cooler temperature can help facilitate the body's natural temperature drop, which occurs during sleep onset.
B. Engaging in regular physical activity, such as taking a long walk during the day, can be beneficial for promoting better sleep. Physical activity during the day can help regulate the sleep-wake cycle, reduce stress, and improve overall sleep quality. Therefore, this statement reflects a positive sleep hygiene practice and does not indicate a need for further education.
C. This statement suggests an understanding of the importance of associating the bed with sleep and avoiding activities that may interfere with sleep, such as paying bills or working in bed. Maintaining the bed as a place primarily for sleep and intimacy can help condition the mind and body to associate the bed with relaxation and sleep.
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