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

Answer and Explanation

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.

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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.

A. Identify the client's preferred relaxation technique to use prior to each step of the therapy. B. Administer an anxiolytic medication 1 hr prior to the scheduled therapy session. C. Expose the client to an excess amount of anxiety-inducing stimulus to extinguish the phobia. D. Ask the client to snap a rubber band worn on the wrist to minimize anxiety when thinking about the phobia.

Correct Answer is A

Explanation

A) Identify the client's preferred relaxation technique to use prior to each step of the therapy:
Systematic desensitization involves gradually exposing the client to the anxiety-inducing stimulus while using relaxation techniques to manage anxiety. Identifying the client's preferred relaxation technique is crucial to help them remain calm and reduce their phobia-related anxiety during each step of the therapy.

B) Administer an anxiolytic medication 1 hr prior to the scheduled therapy session:
While anxiolytic medications can help reduce anxiety, systematic desensitization typically relies on non-pharmacological methods to help the client gradually overcome their phobia. The goal is for the client to develop coping mechanisms without medication.

C) Expose the client to an excess amount of anxiety-inducing stimulus to extinguish the phobia:
Exposing the client to an excess amount of anxiety-inducing stimuli is not appropriate for systematic desensitization. This method, known as flooding, can overwhelm the client and increase their anxiety, potentially worsening the phobia rather than alleviating it.

D) Ask the client to snap a rubber band worn on the wrist to minimize anxiety when thinking about the phobia:
Snapping a rubber band on the wrist is a distraction technique that might provide temporary relief from anxiety. However, it is not a core component of systematic desensitization, which focuses on gradual exposure and the use of relaxation techniques to manage anxiety

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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?

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