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?

Answer: C. Respiratory acidosis

Rationale:

A) Metabolic acidosis: This occurs when there is an excess of acid in the body or a loss of bicarbonate, often due to conditions such as renal failure or severe diarrhea. In chronic bronchitis, the primary issue is related to respiratory function rather than metabolic disturbances.

B) Respiratory alkalosis: This condition results from hyperventilation, leading to excessive loss of carbon dioxide. It is unlikely in a client with chronic bronchitis, who typically experiences difficulty in exhaling fully rather than hyperventilating.

C) Respiratory acidosis: In chronic bronchitis, airflow obstruction and reduced gas exchange can lead to carbon dioxide retention, resulting in respiratory acidosis. Symptoms like dyspnea and increased work of breathing support this imbalance, as the body is unable to adequately expel carbon dioxide.

D) Metabolic alkalosis: This imbalance results from excessive bicarbonate or loss of hydrogen ions, often related to prolonged vomiting or diuretics. It is not characteristic of chronic bronchitis, where the primary concern is respiratory function rather than metabolic processes.

A. Arrange referral for family therapy to deal with home stressors:

While family therapy may be beneficial in addressing underlying issues, suspected abuse must be reported promptly to protect the client's safety. Referral for family therapy can be considered as part of a comprehensive intervention plan but should not delay reporting of suspected abuse.

B. Follow the agency's guidelines for reporting suspected abuse:

Reporting suspected abuse is the first priority when there are concerns about a client's safety. Following the agency's guidelines ensures that the appropriate authorities are notified and that the client receives the necessary protection and support.

C. Check the bruises at the next visit to the client's home:

Delaying action and waiting until the next visit to check the bruises could put the client at further risk of harm. Suspected abuse requires immediate attention, and the nurse should follow established protocols for reporting and intervening in such situations.

D. Institute more frequent visits to the client's home:

While more frequent visits may allow for closer monitoring of the client's condition, suspected abuse should be addressed immediately through appropriate reporting channels. Increasing visit frequency alone may not adequately address the safety concerns and may delay necessary intervention.