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 C
Explanation
C. Dehydration is a state of insufficient fluid intake or excessive fluid loss, leading to electrolyte imbalances and increased concentrations of solutes in the blood. The elevated sodium level (hypernatremia) and slightly elevated glucose level in the context of dehydration are consistent with the laboratory findings. Dehydration can also cause elevated BUN due to decreased kidney perfusion and impaired renal function secondary to hypovolemia. Therefore, dehydration is the most likely condition based on the laboratory findings.
A. SIADH is characterized by excessive release of antidiuretic hormone (ADH), leading to water retention and dilutional hyponatremia (low sodium levels). In this case, the sodium level is elevated, which is not consistent with SIADH. Therefore, SIADH is unlikely.
B. Low-protein diet is not typically associated with the laboratory findings presented. Low protein intake would not directly cause elevated sodium, potassium, glucose, or BUN levels. Therefore, this option is unlikely.
D. Renal failure is characterized by impaired kidney function, resulting in electrolyte imbalances, elevated BUN, and abnormal creatinine levels. However, the creatinine level in this case is within the normal range, suggesting preserved kidney function. Additionally, the elevated sodium level is not typically associated with renal failure. Therefore, renal failure is less likely.
Correct Answer is ["A","B"]
Explanation
A. pH 7.29: A respiratory rate of 6 breaths per minute suggests hypoventilation, which can lead to respiratory acidosis due to retention of carbon dioxide (CO2). A decrease in pH (acidosis) is expected in this scenario.
B. PaCO2 54: In respiratory acidosis, PaCO2 levels are elevated due to inadequate ventilation, leading to CO2 retention. Therefore, an elevated PaCO2 level would be anticipated in this situation.
C. pH 7.51: A pH of 7.51 indicates alkalosis, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
D. PaO2 72: Oxygenation may be impaired in opioid overdose due to respiratory depression, but this PaO2 level is within the normal range. Hypoxemia is not typically a prominent feature of respiratory acidosis unless there are concurrent respiratory conditions or complications. Therefore, this choice is not anticipated.
E. PaCO2 31: A PaCO2 level of 31 indicates hypocapnia, which is not consistent with the expected respiratory acidosis in the context of opioid overdose and hypoventilation. Therefore, this choice is not anticipated.
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