A nurse in an emergency department is admitting a client who has overdosed on antacids and is in a state of metabolic alkalosis. For which of the following manifestations should the nurse monitor?
Diarrhea
Bradycardia
Tinnitus
Tetany
The Correct Answer is D
A) Diarrhea: Metabolic alkalosis is more likely to be associated with constipation rather than diarrhea. Diarrhea is typically a cause of metabolic acidosis due to the loss of bicarbonate in stool, rather than a result of metabolic alkalosis.
B) Bradycardia: Bradycardia is not a typical manifestation of metabolic alkalosis. Alkalosis can lead to arrhythmias, but it generally does not cause a slow heart rate. Instead, tachycardia might occur as the body compensates for the altered acid-base balance.
C) Tinnitus: Tinnitus is not a common symptom of metabolic alkalosis. It is more often associated with aspirin toxicity or other conditions affecting the auditory system, rather than changes in acid-base balance.
D) Tetany: Tetany is a common manifestation of metabolic alkalosis. The alkalosis causes a decrease in ionized calcium levels, which increases neuromuscular excitability and can lead to muscle cramps, spasms, and tetany. This is a key sign for nurses to monitor as it indicates significant electrolyte disturbances associated with the alkalotic state.
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Related Questions
Correct Answer is A
Explanation
A) Orthostatic hypotension: Anemia often results in decreased blood volume and oxygen-carrying capacity, which can cause orthostatic hypotension. This condition is characterized by a sudden drop in blood pressure when moving from a sitting or lying position to standing, leading to dizziness or fainting.
B) Clubbing of the nail beds: Clubbing is typically associated with chronic hypoxia and long-term respiratory or cardiovascular diseases, rather than anemia. It involves the enlargement of the fingertips and changes in the angle of the nail bed.
C) Conjunctivitis: Conjunctivitis is an inflammation of the conjunctiva, usually caused by infections, allergies, or irritants. It is not a common manifestation of anemia.
D) Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism or other metabolic disorders rather than anemia. Individuals with anemia are more likely to experience cold intolerance due to reduced oxygen delivery to tissues.
Correct Answer is D
Explanation
A) Protective environment
This type of isolation is used for clients with weakened immune systems to protect them from infections. It is not necessary for pertussis, which requires droplet precautions to prevent spread.
B) Airborne precautions
These are used for diseases that are spread through tiny droplets that remain in the air, such as tuberculosis. Pertussis spreads through larger respiratory droplets, not lingering in the air, so airborne precautions are not needed.
C) Contact precautions
These are used for infections spread by direct touch or contact with surfaces. Pertussis primarily spreads through respiratory droplets rather than direct contact, making contact precautions unnecessary.
D) Droplet precautions
Droplet precautions are appropriate for pertussis, as it spreads via respiratory droplets when an infected person coughs or sneezes. This involves wearing masks and maintaining distance to prevent transmission.
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