The nurse observed that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, and rapid respirations. How would the nurse document this observation in the medical record?
Bradypnea
Kussmaul's respirations
Cheyne-Stokes respirations
Biot's respirations
The Correct Answer is B
Choice A reason: This is incorrect because bradypnea is a term for slow breathing, usually less than 12 breaths per minute. The client is breathing rapidly, not slowly.
Choice B reason: This is correct because Kussmaul's respirations are a type of breathing pattern that is deep, regular, and rapid, usually more than 20 breaths per minute. Kussmaul's respirations are a sign of metabolic acidosis, which occurs in diabetic ketoacidosis due to the accumulation of ketones in the blood. The client is trying to exhale the excess carbon dioxide and lower the acidity of the blood.
Choice C reason: This is incorrect because Cheyne-Stokes respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) alternating with periods of rapid breathing. Cheyne-Stokes respirations are a sign of cerebral dysfunction, such as stroke, brain injury, or coma.
Choice D reason: This is incorrect because Biot's respirations are a type of breathing pattern that is irregular, with periods of apnea (no breathing) interspersed with periods of normal breathing. Biot's respirations are a sign of brainstem damage, such as meningitis, encephalitis, or head trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Stroke is not a cause of hyponatremia, but rather a possible complication of it. Hyponatremia is a condition where the sodium level in the blood is too low, which can affect the brain function and cause symptoms such as confusion, seizures, or coma. Stroke is a condition where the blood supply to a part of the brain is interrupted, which can cause brain damage and neurological deficits.
Choice B reason: Dehydration is not a cause of hyponatremia, but rather a cause of hypernatremia. Dehydration is a condition where the body loses more fluids than it takes in, which can affect the blood volume and the electrolyte balance. Dehydration can cause hypernatremia, which is a condition where the sodium level in the blood is too high, which can also affect the brain function and cause symptoms such as thirst, dry mouth, or lethargy.
Choice C reason: Increased secretion of aldosterone is not a cause of hyponatremia, but rather a cause of hypokalemia. Aldosterone is a hormone that regulates the sodium and potassium levels in the body by increasing the reabsorption of sodium and the excretion of potassium in the kidneys. Increased secretion of aldosterone can cause hypokalemia, which is a condition where the potassium level in the blood is too low, which can affect the muscle and nerve function and cause symptoms such as weakness, cramps, or arrhythmias.
Choice D reason: Congestive heart failure (CHF) is a cause of hyponatremia, as it is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to fluid retention and edema, which can dilute the sodium level in the blood and cause hyponatremia. CHF can also stimulate the release of antidiuretic hormone (ADH), which increases the reabsorption of water in the kidneys and further lowers the sodium level in the blood.
Correct Answer is C
Explanation
Choice A reason: Metabolic alkalosis is a condition where the pH and the HCO3- are both elevated, indicating a loss of acids or a gain of bases in the body. This is not the case for this patient, as his HCO3- is within the normal range of 22 to 26 mEq/L.
Choice B reason: Respiratory acidosis is a condition where the pH and the PaCO2 are both low, indicating a retention of carbon dioxide in the lungs due to hypoventilation. This is not the case for this patient, as his pH is high and his PaCO2 is low.
Choice C reason: Respiratory alkalosis is a condition where the pH and the PaCO2 are both high, indicating a loss of carbon dioxide in the lungs due to hyperventilation. This is the case for this patient, as his pH is above the normal range of 7.35 to 7.45 and his PaCO2 is below the normal range of 35 to 45 mm Hg. This condition is uncompensated, as his HCO3- is within the normal range and has not changed to counteract the pH imbalance.
Choice D reason: Metabolic acidosis is a condition where the pH and the HCO3- are both low, indicating a gain of acids or a loss of bases in the body. This is not the case for this patient, as his pH is high and his HCO3- is within the normal range.
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