A nurse is assessing a client who has acute kidney failure and is in a state of metabolic acidosis. The nurse should monitor for which of the following manifestations?
Bounding peripheral pulses
Hyperreflexia
Cool skin
Hypotension
The Correct Answer is D
A) Bounding peripheral pulses: Metabolic acidosis typically does not cause bounding peripheral pulses. In metabolic acidosis, vasodilation might occur, but it usually leads to weaker, not bounding, pulses due to decreased cardiac output and blood pressure.
B) Hyperreflexia: Hyperreflexia is not commonly associated with metabolic acidosis. Instead, metabolic acidosis may cause symptoms like muscle weakness or fatigue due to the effect of acid-base imbalance on neuromuscular function.
C) Cool skin: While cool skin can sometimes be associated with poor perfusion in severe cases, it is not a direct manifestation of metabolic acidosis. Metabolic acidosis more commonly affects internal physiology rather than peripheral skin temperature directly.
D) Hypotension: Hypotension is a common manifestation of metabolic acidosis. The acidosis leads to vasodilation and decreased cardiac contractility, resulting in a drop in blood pressure. This is a critical sign for the nurse to monitor as it indicates the severity of the acid-base imbalance and its effect on the cardiovascular system.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) A yellowed sclera:
A yellowed sclera is typically associated with jaundice, which is related to liver conditions, not acute angle-closure glaucoma. This symptom is not indicative of glaucoma.
B) Brisk pupil reactivity:
In acute angle-closure glaucoma, the pupil is often mid-dilated and sluggish to react to light due to increased intraocular pressure. Brisk pupil reactivity is not a characteristic finding in this condition.
C) Client reports a curtainlike obstruction over the visual field:
A curtainlike obstruction over the visual field is usually associated with retinal detachment, not acute angle-closure glaucoma. This description does not align with the symptoms of glaucoma.
D) Client reports seeing colored halos around lights:
Seeing colored halos around lights is a classic symptom of acute angle-closure glaucoma. This occurs due to the elevated intraocular pressure affecting the corneal surface and causing light diffraction. This manifestation is a key indicator of the condition.
Correct Answer is A
Explanation
A) Consume a diet low in cholesterol: A diet low in cholesterol is beneficial for preventing cholelithiasis (gallstones), as high cholesterol levels can contribute to the formation of cholesterol stones in the gallbladder. By reducing dietary cholesterol, the risk of gallstone formation can be minimized.
B) Increase your intake of refined carbohydrates: Increasing the intake of refined carbohydrates can lead to higher levels of triglycerides and cholesterol in the blood, which can promote the formation of gallstones. This dietary change is not recommended for preventing cholelithiasis.
C) Consume a diet high in calories: A high-calorie diet, especially if it leads to obesity, increases the risk of developing gallstones. Obesity is a significant risk factor for cholelithiasis, and a high-calorie diet can contribute to weight gain and the development of gallstones.
D) Reduce your dietary fiber intake: Dietary fiber helps in reducing cholesterol levels by binding bile acids in the intestines, which in turn can prevent the formation of cholesterol gallstones. Reducing fiber intake would be counterproductive and increase the risk of cholelithiasis.
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