A nurse is caring for a client who has diabetic ketoacidosis (DK
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
The Correct Answer is B
Choice A reason: Metabolic alkalosis is a condition characterized by an elevated pH in body tissues, typically due to an excess of bicarbonate or a loss of hydrogen ions. This condition is not associated with Kussmaul breathing. Kussmaul breathing is a deep and labored breathing pattern often seen in patients with metabolic acidosis, not alkalosis. In metabolic alkalosis, the body does not need to expel excess acid through rapid breathing, so Kussmaul respirations are not observed.
Choice B reason: Metabolic acidosis is a condition where there is an excess of acid in the body due to the accumulation of acid or the loss of bicarbonate. This condition is commonly seen in diabetic ketoacidosis (DKA), where the body produces high levels of ketones, leading to acidosis. Kussmaul breathing is a compensatory mechanism in metabolic acidosis, where the body attempts to reduce the acid level by expelling carbon dioxide through rapid, deep breaths. This type of breathing helps to lower the blood’s acidity by reducing the concentration of carbon dioxide, which is an acid.
Choice C reason: Respiratory alkalosis is a condition where there is a decrease in carbon dioxide levels in the blood due to excessive breathing or hyperventilation. This condition leads to an increase in blood pH, making it more alkaline. Kussmaul breathing is not associated with respiratory alkalosis because it is a response to metabolic acidosis, not a condition where the body is already expelling too much carbon dioxide.
Choice D reason: Respiratory acidosis is a condition where there is an excess of carbon dioxide in the blood due to inadequate respiration. This leads to a decrease in blood pH, making it more acidic. While respiratory acidosis involves an acidic environment, Kussmaul breathing is specifically a response to metabolic acidosis, not respiratory acidosis. In respiratory acidosis, the body would not use Kussmaul respirations as a compensatory mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason:
Heart murmur is a common manifestation of valvular dysfunction. It occurs when there is turbulent blood flow across a damaged or abnormal heart valve. This can be due to stenosis (narrowing of the valve) or regurgitation (leakage of the valve). The murmur’s characteristics, such as timing, location, and intensity, can help in diagnosing the specific type of valvular disease. For example, a systolic murmur might indicate aortic stenosis or mitral regurgitation, while a diastolic murmur could suggest aortic regurgitation or mitral stenosis.
Choice B reason:
Chest pain is another symptom that can be associated with valvular dysfunction. This pain can result from increased workload on the heart due to inefficient blood flow through the valves. Conditions like aortic stenosis can lead to angina (chest pain) because the heart muscle may not receive enough oxygenated blood. This symptom is particularly concerning and warrants immediate medical attention to prevent complications such as myocardial infarction.
Choice C reason:
Varicose veins are not typically associated with valvular dysfunction in the heart. They are more related to issues with the veins in the legs, where the valves that prevent backflow of blood become weakened or damaged. This condition is generally referred to as chronic venous insufficiency and is not directly linked to the heart’s valvular problems.
Choice D reason:
Palpitations, or the sensation of irregular or rapid heartbeats, are common in clients with valvular dysfunction. These can occur due to arrhythmias, which are often seen in conditions like mitral valve prolapse or aortic regurgitation. The irregular heartbeats can be a result of the heart trying to compensate for the inefficient blood flow caused by the faulty valve.
Choice E reason:
Abdominal pain is not a typical manifestation of valvular dysfunction. While severe heart conditions can sometimes lead to generalized symptoms, abdominal pain is more commonly associated with gastrointestinal issues rather than heart valve problems. Therefore, it is not a primary symptom to anticipate in clients with valvular dysfunction.
Correct Answer is A
Explanation
Choice A reason:
“I need to walk slowly as I lose my balance often” is a significant safety concern for a client with peripheral artery disease (PAD). Balance issues can increase the risk of falls, which can lead to serious injuries, especially in clients with compromised circulation. PAD can cause muscle weakness and pain, which may contribute to balance problems. Reporting this symptom to the provider is crucial for further evaluation and intervention to prevent falls and improve the client’s mobility and safety.
Choice B reason:
“I have a small-healed area on my spine that is painful” is not directly related to peripheral artery disease. While pain in different parts of the body can be concerning, this statement does not indicate an immediate safety risk associated with PAD. However, it is still important for the nurse to document and monitor this symptom, as it could be related to other underlying conditions.
Choice C reason:
“I don’t go out much because of the pain in my legs” is a common symptom of PAD known as claudication, which is pain caused by too little blood flow during exercise. While this statement indicates a significant impact on the client’s quality of life, it does not pose an immediate safety risk that requires urgent reporting. The nurse should provide education on managing claudication and encourage the client to engage in supervised exercise programs to improve circulation.
Choice D reason:
“It makes me sad that I can’t keep up with my grandchildren” reflects the emotional and psychological impact of PAD on the client’s life. While this is an important aspect of the client’s overall well-being, it does not represent an immediate safety concern. The nurse should address the client’s emotional health and consider referring them to a mental health professional for support.
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