An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating.
The nurse anticipates the client developing which acid-base imbalance?
Metabolic alkalosis.
Respiratory alkalosis.
Metabolic acidosis.
Respiratory acidosis.
The Correct Answer is B
The correct answer is choice B.
Choice A rationale: Metabolic alkalosis is caused by a loss of acid or a gain of base. It is not typically associated with anxiety or hyperventilation.
Choice B rationale: Respiratory alkalosis is caused by hyperventilation, which leads to a decrease in carbon dioxide levels in the blood. This can occur in response to anxiety, pain, or other stressors.
Choice C rationale: Metabolic acidosis is caused by a buildup of acid in the blood or a loss of bicarbonate. It is not typically associated with anxiety or hyperventilation.
Choice D rationale: Respiratory acidosis is caused by hypoventilation, which leads to an increase in carbon dioxide levels in the blood. It is not typically associated with anxiety or hyperventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. “You seem quite frightened right now.”.
Choice A rationale:
While reassuring the client that no one will hurt them is well-intentioned, it may not effectively address the client’s immediate emotional state or validate their feelings.
Choice B rationale:
Acknowledging the client’s fear helps validate their emotions and opens a pathway for further therapeutic communication. It shows empathy and understanding, which can help build trust and provide comfort.
Choice C rationale:
Telling the client they are in a safe place is reassuring, but it may not fully address the client’s immediate emotional distress or validate their feelings.
Choice D rationale:
Asking the client what they would like the nurse to do to protect them might reinforce the delusion and could potentially escalate the situation. It is more effective to acknowledge the client’s feelings and provide reassurance.
Correct Answer is B
Explanation
Choice A rationale:
Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.
Choice B rationale:
Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.
Choice C rationale:
Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.
Choice D rationale:
Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.
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