A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Circumoral numbness and tingling

Muscle flaccidity

Decreased level of consciousness

Cool, clammy skin

Answer and Explanation

The Correct Answer is C

Acute respiratory acidosis occurs when there is inadequate excretion of carbon dioxide due to respiratory dysfunction, leading to an increase in carbon dioxide levels (hypercapnia) and subsequent acidosis (decrease in pH).

Manifestations of acute respiratory acidosis include:

A. Circumoral numbness and tingling - This is associated with respiratory alkalosis, not acidosis. B. Muscle flaccidity - This is more commonly seen in hyperkalemia or conditions affecting neuromuscular transmission. C. Decreased level of consciousness - This is a key manifestation of acute respiratory acidosis due to the effects of hypercapnia on the central nervous system. D. Cool, clammy skin - This is not typically associated with acute respiratory acidosis; instead, it might be seen in shock or hypoperfusion states.

Therefore, the nurse should expect to find a decreased level of consciousness in a client experiencing acute respiratory acidosis.

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Correct Answer is ["A","C","D"]

Explanation

(A) Correctly identify clients prior to administering medications: This is a key goal of the National Patient Safety Goals (NPSGs). Correctly identifying patients before administering medications helps to prevent medication errors and ensures patient safety.

(B) Educate clients about health promotion and prevention: While this is an important aspect of nursing care, it is not specifically listed as a National Patient Safety Goal.

(c) Prevent catheter-associated urinary tract infections in clients: Preventing healthcare-associated infections, including catheter-associated urinary tract infections, is a major focus of the NPSGs.

(D) Improve communication among staff members: Effective communication among healthcare providers is crucial for patient safety and is a key goal of the NPSGs.

(E) Increase job satisfaction for staff members: While job satisfaction can indirectly impact patient safety, it is not a specific goal of the NPSGs. The NPSGs are primarily focused on direct measures to improve patient safety.

A. Kernig's sign B. Brudzinski's sign C. Chvostek's sign D. Cullen's sign

Correct Answer is C

Explanation

(A) Kernig’s sign: Kernig’s sign is a clinical sign in which severe stiffness of the hamstrings causes an inability to straighten the leg when the hip is flexed to 90 degrees. It is commonly associated with meningitis, not hypocalcemia.

(B) Brudzinski’s sign: Brudzinski’s sign is a symptom of meningitis. It is not associated with hypocalcemia.

(C) Chvostek’s sign: This is the most appropriate answer. Chvostek’s sign is a clinical sign of existing nerve hyperexcitability (tetany) seen in hypocalcemia. It refers to an abnormal reaction to the stimulation of the facial nerve.

(D) Cullen’s sign: Cullen’s sign is a medical term referring to superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is not associated with hypocalcemia.

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A nurse is collecting data from a client who has pneumonia and is experiencing acute respiratory acidosis. Which of the following manifestations should the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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