A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?

Respiratory alkalosis

Metabolic acidosis

Respiratory acidosis

Metabolic alkalosis

Answer and Explanation

The Correct Answer is C

Choice A reason: Respiratory alkalosis is typically associated with hyperventilation, which is not common in acute pulmonary edema.

Choice B reason: Metabolic acidosis can occur in pulmonary edema due to tissue hypoxia and lactic acid production, but respiratory acidosis is more directly related to the primary problem of gas exchange.

Choice C reason: Respiratory acidosis is likely in acute pulmonary edema due to impaired gas exchange and CO2 retention.

Choice D reason: Metabolic alkalosis is not typically associated with acute pulmonary edema and is less likely than respiratory acidosis in this context.

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Correct Answer is A

Explanation

Choice A Reason:Grandiosity refers to an exaggerated sense of one's importance, power, knowledge, or identity—even with little evidence to support this. In bipolar disorder, grandiosity can occur during both manic and hypomanic episodes. Individuals experiencing grandiosity may believe they have special powers, abilities, or are destined for greatness. This behavior aligns with the client's statement about revolutionizing the industry, which reflects an inflated sense of self-importance.

Choice B Reason:Flight of ideas is characterized by rapid, continuous, and often disjointed thoughts. It is a symptom commonly seen in manic episodes of bipolar disorder. However, the client's statement does not specifically indicate flight of ideas.

Choice C Reason:Confabulation refers to the production of fabricated or distorted memories or information. It is not directly related to the client's statement about revolutionizing the industry

Choice D Reason:Clang associations involve the use of rhyming or similar-sounding words without logical connections. While it is a symptom seen in some mental health conditions, it is not directly applicable to the client's behavior described in the question.

A. Assure that a staff member stays with the client at all times. B. Inform the provider about the client's statement. C. Question the client about a suicide plan and method. D. Administer a prescribed anti-anxiety medication, instituting mouth checks to ensure it is swallowed.

Correct Answer is C

Explanation

Choice A reason: Ensuring safety is important, but it does not directly address the immediate risk of suicide as effectively as understanding the client's intentions.

Choice B reason: Informing the provider is a critical step, but it should follow after assessing the immediate risk to the client's safety.

Choice C reason: Questioning the client about a suicide plan and method is the most immediate and direct way to assess the risk of suicide and take appropriate safety measures.

Choice D reason: Administering medication is important for managing anxiety but does not take precedence over assessing the risk of suicide in a client expressing such thoughts.

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A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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