Colleen, a 19 year old Freshman, was drinking alcohol at a frat party. She stupors, falls and hits her head on the ground. Her friend Julie dials "911" because Colleen is now unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Colleen at risk for if medical attention is not provided?
Metabolic Acidosis
Respiratory Acidosis
Respiratory Alkalosis
Metabolic Alkalosis
The Correct Answer is B
Respiratory acidosis is a primary acid-base imbalance that occurs when there is an excess of carbon dioxide (CO2) in the body due to impaired ventilation or inadequate removal of CO2 from the lungs. In this case, Colleen's depressed ventilation, indicated by shallow and slow respirations, can lead to inadequate elimination of CO2 from her body. The excessive CO2 levels can result in an accumulation of carbonic acid (H2CO3) in the blood, leading to an increase in acidity and a decrease in pH.
The profuse bleeding from both ears indicates a potential head injury, which can lead to decreased neurological function and impaired control over the respiratory center in the brain. This can further contribute to depressed ventilation and the development of respiratory acidosis. Metabolic acidosis, characterized by a decrease in bicarbonate (HCO3-) levels or an increase in non-carbonic acids in the blood, is not the primary acid-base imbalance in this case since the scenario does not provide information indicating a primary metabolic disorder. Respiratory alkalosis, characterized by decreased levels of CO2 in the blood, leading to increased pH and alkalinity, is not the primary acid-base imbalance in this case. The depressed ventilation and associated increase in CO2 levels indicate the opposite, respiratory acidosis. Metabolic alkalosis, characterized by an increase in bicarbonate levels or a decrease in non-carbonic acids, is not the primary acid-base imbalance in this case as the scenario does not provide information indicating a primary metabolic disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Pain tolerance refers to the maximum level of pain that an individual can tolerate without significant distress. It is influenced by various factors, including psychological and emotional factors. While emotions such as anger, boredom, and introversion can have an impact on a person's pain perception and experience, sleep plays a significant role in pain tolerance. During sleep, the body is in a state of rest and relaxation, allowing for decreased sensory input and potentially reducing pain perception. Sleep provides an opportunity for the body to repair and heal, which can contribute to improved pain tolerance. Additionally, sleep promotes the release of endogenous opioids, which are natural pain-relieving substances produced by the body.
Correct Answer is ["C","D","E"]
Explanation
Crackles and wheezing indicate the presence of excessive mucus or secretions in the airways, which may require suctioning to clear the airway and improve breathing.
The presence of serosanguineous drainage on the tracheostomy dressing may indicate increased mucus production or bleeding, suggesting the need for suctioning to remove secretions or assess for any bleeding complications.
Regular suctioning is necessary to maintain a patent airway for patients with a tracheostomy. If suctioning was performed more than 4 hours ago, it may be time for another suctioning session to prevent the accumulation of secretions and maintain airway clearance. While a fever may indicate an underlying infection or inflammation, it does not specifically indicate the need for suctioning. The decision to suction should be based on the patient's respiratory assessment and the presence of respiratory symptoms.
While patient requests and preferences are important, the need for suctioning should be determined based on clinical indicators and assessment findings rather than solely relying on patient requests.
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