The nurse identifies which client to be at risk for developing metabolic alkalosis? The client who:
has been vomiting for three days.
has had diarrhea for the past 24 hours.
has overdosed on heroin.
is admitted with an asthma exacerbation.
The Correct Answer is A
A. Vomiting results in loss of hydrochloric acid (HCl) from the stomach, leading to a loss of chloride ions (Cl-) and hydrogen ions (H+) from the body. This loss of hydrogen ions can result in an accumulation of bicarbonate ions (HCO3-) relative to hydrogen ions, leading to metabolic alkalosis. Therefore, this client is at risk for developing metabolic alkalosis due to prolonged vomiting.
B. Client who has had diarrhea for the past 24 hours: Diarrhea leads to loss of bicarbonate ions (HCO3-) from the body along with fluid and electrolytes. However, metabolic alkalosis is less likely to occur with diarrhea alone because the loss of bicarbonate ions is usually balanced by the loss of chloride ions (Cl-) and hydrogen ions (H+). Therefore, while diarrhea can lead to metabolic acidosis in some cases, it is less likely to cause metabolic alkalosis.
C. Client who has overdosed on heroin: Heroin overdose is not directly associated with metabolic alkalosis. In the context of heroin overdose, respiratory depression leading to respiratory acidosis is a more immediate concern. Therefore, this client is not at risk for developing metabolic alkalosis due to heroin overdose.
D. Client who is admitted with an asthma exacerbation: Asthma exacerbation can lead to respiratory alkalosis due to hyperventilation and excessive elimination of carbon dioxide (CO2) from the body. However, metabolic alkalosis is not a typical consequence of asthma exacerbation alone. Therefore, while this client may experience respiratory alkalosis, they are not at risk for developing metabolic alkalosis solely due to asthma exacerbation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Narcolepsy is a chronic neurological disorder characterized by excessive daytime sleepiness and other symptoms such as cataplexy (sudden loss of muscle tone), sleep paralysis, and hallucinations. While lifestyle modifications and behavioral strategies may help manage symptoms, medications are often necessary to control narcolepsy symptoms effectively. Therefore, if a client with narcolepsy states that they will not need medications, further teaching is indeed needed.
B. Narcoleptic attacks, or sleep attacks, can indeed last seconds to minutes. They are characterized by sudden and uncontrollable episodes of sleepiness or sleep onset, which can occur during daytime activities.
C. Narcoleptic attacks can occur suddenly, even when the individual is alert and engaged in activities. These attacks are unpredictable and can significantly disrupt daily life.
D. Emotional triggers, such as stress, excitement, or anger, can sometimes precipitate or exacerbate narcoleptic symptoms, including sleep attacks and cataplexy. However, not all individuals with narcolepsy experience triggers in the same way, and triggers can vary among individuals. Therefore, this statement may or may not be true for the individual in question.
Correct Answer is D
Explanation
D. This is the most appropriate technique for evaluating the success of teaching a client a psychomotor skill. A return demonstration involves the client independently performing the skill they have been taught while the nurse observes. This allows the nurse to assess the client's ability to execute the skill correctly, including aspects such as technique, coordination, and safety precautions. Additionally, the nurse can provide immediate feedback and correction if necessary, enhancing the client's learning experience.
A. While answering oral questions can assess the client's understanding of theoretical or conceptual knowledge, it may not effectively evaluate their ability to perform a psychomotor skill. Psychomotor skills involve physical actions and coordination, which cannot be adequately assessed through verbal responses alone.
B. Participating in a discussion group can facilitate sharing of experiences and perspectives among clients, but it may not be the most effective method for evaluating the client's ability to perform a psychomotor skill. Discussion groups are more suitable for exploring attitudes, beliefs, and understanding of concepts rather than assessing physical skills.
C. Written tests typically assess cognitive understanding and retention of information rather than the ability to perform psychomotor skills. While written tests can evaluate knowledge about the steps involved in a skill, they do not directly assess the client's ability to execute the skill itself.
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