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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
(A) Limit the client’s visitors to one at a time: While it’s important to maintain a peaceful environment for the client, limiting visitors may not be necessary unless the client’s condition is being negatively affected by too many visitors or if there are restrictions due to infection control.
(B) Avoid touching the client: Touch can be a powerful form of communication, especially when a client is unresponsive. Gentle touch can convey caring and presence, so avoiding touch is not typically recommended unless there’s a specific reason to do so (like if the client is in pain).
(C) Continue to talk to the client as if they are alive: This is the most appropriate answer. Even if a client is unresponsive, they may still be able to hear and understand. Continuing to talk to the client can provide comfort and reassurance.
(D) Whisper when talking in the client’s room: Whispering is not necessary and can even be confusing or distressing for the client. It’s better to speak in a normal, calm, and reassuring voice.
Correct Answer is C
Explanation
A. "My mouth is very dry."
Dry mouth is a common side effect of lorazepam, but it does not directly indicate the effectiveness of the medication in reducing preoperative anxiety.
B. "My leg feels numb."
Numbness in the leg is not a typical effect of lorazepam and does not indicate the effectiveness of the medication in reducing preoperative anxiety.
C. "I feel very sleepy."
Feeling sleepy or drowsy is a common side effect of lorazepam, and it indicates that the medication has effectively reduced the client's preoperative anxiety.
D. "I am not hungry any longer."
Decreased appetite can be a side effect of lorazepam, but it is not a direct indicator of the medication's effectiveness in reducing preoperative anxiety.
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