Exam One Flashcards
A nurse is caring for a young adult. Which goal is priority? a. Maintain peer relationships. b. Maintain family relationships. c. Maintain parenteral relationships. d. Maintain recreational relationships.
ANS: B
Family is important during young adulthood. Challenges may include the demands of working and raising families. Peer is more important in the adolescent years. Young adults are much freer from parental control. While recreation is important, the family and work are the priorities in young adults.
The nurse is caring for a hospitalized young-adult male who works as a dishwasher at a local restaurant. He states that he would like to get a better job but has no education. How can the nurse best assist this patient psychosocially?
a.
By providing information and referrals
b.
By focusing on the patient’s medical diagnoses
c.
By telling the patient that he needs to go back to school
d.
By expecting the patient to be flexible in decision making
ANS: A
Support from the nurse, access to information, and appropriate referrals provide opportunities for achievement of a patient’s potential. Health is not merely the absence of disease (focusing on medical diagnoses) but involves wellness in all human dimensions. Telling a patient what to do (go back to school) is inappropriate. Each person (not the nurse) needs to make these decisions based on individual factors. Insecure persons tend to be more rigid in making decisions.
Which goal is priority when the nurse is caring for a middle-aged adult? a. Maintain immediate family relationships. b. Maintain future generation relationships. c. Maintain personal career relationships. d. Maintain work relationships.
ANS: B
Many middle-aged adults find particular joy in helping their children and other young people become productive and responsible adults. While immediate family is important, this goal is priority in young adults, not as important in middle-aged adults. During this period, personal and career achievements have often already been experienced; therefore, these goals are not priority.
A nurse is teaching young adults about health risks. Which statement from a young adult indicates a correct understanding of the teaching?
a.
“It’s probably safe for me to start smoking. At my age, there’s not enough time for cancer to develop.”
b.
“My mother had appendicitis, so this increases my chance for developing appendicitis.”
c.
“Controlling the amount of stress in my life may decrease the risk of illness.”
d.
“I don’t do drugs. I do drink coffee, but caffeine is not a drug.”
ANS: C
Lifestyle habits that activate the stress response increase the risk of illness; so, controlling this will decrease risk. Smoking is a well-documented risk factor for pulmonary, cardiac, and vascular disease as well as cancer in smokers and in individuals who receive secondhand smoke. The presence of certain chronic illnesses (not acute illnesses—appendicitis) in the family increases the family member’s risk of developing a disease. Caffeine is a naturally occurring legal stimulant that is readily available. Caffeine stimulates catecholamine release, which, in turn, stimulates the central nervous system; it also increases gastric acid secretion, heart rate, and basal metabolic rate.
A nurse is choosing an appropriate topic for a young-adult health fair. Which topic should the nurse include? a. Retirement b. Menopause c. Climacteric factors d. Unplanned pregnancies
ANS: D
Unplanned pregnancies are a continued source of stress that can result in adverse health outcomes for the mother (young adult), infant, and family. Retirement is an issue for middle-aged, not young adults. The onset of menopause and the climacteric affect the sexual health of the middle-aged adult, not the young adult.
A nurse is assessing the risk of intimate partner violence (IPV) for patients. Which population should the nurse focus on most for IVP? a. White males b. Pregnant females c. Middle-aged adults d. Nonsubstance abusers
ANS: B
The greatest risk of violence occurs during the reproductive years. A pregnant woman has a 35.6% greater risk of being a victim of IPV than a nonpregnant woman. White males, middle-aged adults, and nonsubstance abusers are not as high risk as pregnant women.
A patient states that she is pregnant and concerned because she does not know what to expect, and she wants her partner to play an active part in the birthing process. Which information should the nurse share with the patient?
a.
Lamaze classes can prepare pregnant women and their partners for what is coming.
b.
The frequency of sexual intercourse is key to helping the husband feel valued.
c.
After the birth, the stress of pregnancy will disappear and will be replaced by relief.
d.
After the baby is born, the wife should accept the extra responsibilities of motherhood.
ANS: A
Childbirth education classes (like Lamaze) can prepare pregnant women, their partners, and other support persons to participate in the birthing process. The psychodynamic aspect of sexual activity is as important as the type or frequency of sexual intercourse to young adults; however, this does not relate to the issue the patient reports (lack of knowledge and participation). The stress that many women experience after childbirth has a significant impact on the health of postpartum women. Ideally partners should share all responsibilities; however, this does not relate to the patient’s concerns.
Which information from the nurse indicates a correct understanding of emerging adulthood? a. It is a type of young adulthood. b. It is a type of extended adolescence. c. It is a type of independent exploration. d. It is a type of marriage and parenthood.
ANS: C
This newly identified stage of development from age 18 to 25 (emerging adulthood) has been described as neither an extended adolescence, as it is much freer from parental control and is much more a period of independent exploration, nor young adulthood, as most young people in their twenties have not made the transitions historically associated with adult status, especially marriage and parenthood.
A nurse is planning care for a 30 year old. Which goal is priority? a. Refine self-perception. b. Master career plans. c. Examine life goals. d. Achieve intimacy.
ANS: B
From 29 to 34, the person directs enormous energy toward achievement and mastery of the surrounding world. The years from 35 to 43 are a time of vigorous examination of life goals and relationships. Between the ages of 23 and 28, the person refines self-perception and ability for intimacy.
A nurse is planning care for young-adult patients. Which information should the nurse consider when planning care?
a.
Fertility issues do not occur in young adulthood.
b.
Young adults tend to suffer more from severe illness.
c.
Substance abuse is easy to observe in young-adult patients.
d.
Young adults are quite active but are at risk for illness in later years
ANS: D
Young adults are generally active and experience severe illnesses less frequently. However, their lifestyles may put them at risk for illnesses or disabilities during their middle or older-adult years. An estimated 10% to 15% of reproductive couples are infertile, and many are young adults. Substance abuse is not always diagnosable, particularly in its early stages.
During a routine physical assessment, the nurse obtaining a health history notes that a 50-year-old female patient reports pain and redness in the right breast. Which action is best for the nurse to take in response to this finding?
a.
Assess the patient as thoroughly as possible.
b.
Explain to the patient that breast tenderness is normal at her age.
c.
Tell the patient that redness is not a cause for concern and is quite common.
d.
Inform her that redness is the precursor to normal unilateral breast enlargement.
ANS: A
A comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed intervention. Redness or painful breasts are abnormal physical assessment findings in the middle-aged adult. Increased size of one breast is an abnormal physical assessment finding in the middle-aged adult.
A 55-year-old female presents to the outpatient clinic describing irregular menstrual periods and hot flashes. Which information should the nurse share with the patient?
a.
The patient’s assessment points toward normal menopause.
b.
Those symptoms are normal when a woman undergoes the climacteric.
c.
An assessment is not really needed because these problems are normal for older women.
d.
The patient should stop regular exercise because that is probably causing these symptoms.
ANS: A
The most significant physiological changes during middle age are menopause in women and the climacteric in men. Menopause typically occurs between 45 and 60 years of age. The nurse should continue with the examination because a comprehensive assessment offers direction for health promotion recommendations, as well as for planning and implementing any acutely needed interventions. Exercise should not be stopped, especially in middle-aged adults.
The nurse is teaching a class to pregnant women about common physiological changes during pregnancy. Which information should the nurse include in the teaching session?
a.
Pregnancy is not a time to be having sexual activity.
b.
Urinary frequency will occur early in the pregnancy.
c.
Breast tenderness should be reported as soon as possible.
d.
Late in the pregnancy Braxton Hicks contraction may occur.
ANS: D
During the third trimester (late pregnancy), increases in Braxton Hicks contractions (irregular, short contractions), fatigue, and urinary frequency (not early) occur. Normally, women commonly have morning sickness, breast enlargement and tenderness, and fatigue. Women need to be reassured that sexual activity will not harm the fetus.
A nurse discusses the risks of repeated sun exposure with a young-adult patient. Which response will the nurse most expect from this patient?
a.
“I should consider participating in a health fair about safe sun practices.”
b.
“I’ll make an appointment with my doctor right away for a full skin check.”
c.
“I’ve had this mole my whole life. So, what if it changed color? My skin is fine.”
d.
“I have a mole that has been bothering me. I’ll call my family doctor for an appointment to get it checked.”
ANS: C
Most typically young adults would say that their skin is fine. Young adults often ignore physical symptoms and often postpone seeking health care. Making an appointment right away with the doctor and participating in health fairs are not typical behaviors of young adults for the same reason.
Upon assessment of a middle-aged adult, the nurse observes uneven weight bearing and decreased range of joint motion. Which area is priority? a. Abuse potential b. Fall precautions c. Stroke prevention d. Self-esteem issues
ANS: B
With uneven weight bearing and decreased range of joint motion, falling is a priority. Abuse potential would indicate other findings such as bruising or unkept appearance. While stroke prevention is important in a middle-aged adult, these are not the signs of stroke. While self-esteem issues may arise from physical changes, safety is a priority over self-esteem issues.
A young-adult patient is brought to the hospital by police after crashing the car in a high-speed chase when trying to avoid arrest for spousal abuse. Which action should the nurse take?
a.
Question the patient about drug use.
b.
Offer the patient a cup of coffee to calm nerves.
c.
Discretely assess the patient for sexually transmitted infections.
d.
Deal with the issue at hand, not asking about previous illnesses.
ANS: A
Reports of arrests because of driving while intoxicated, wife or child abuse, or disorderly conduct are reasons for the nurse to investigate the possibility of drug abuse more carefully. Caffeine is a naturally occurring legal stimulant that stimulates the central nervous system and is not the choice for calming nerves. Although sexually transmitted infections occur in the young adult, this is not an action a nurse should take in this situation. The nurse may obtain important information by making specific inquiries about past medical problems, changes in food intake or sleep patterns, and problems of emotional lability.
A nurse determines that a middle-aged patient is a typical example of the “sandwich generation.” What did the nurse discover the patient is caught between?
a.
Job responsibilities or family responsibilities
b.
Stopping old habits and starting new ones
c.
Caring for children and aging parents
d.
Advancing in career or retiring
ANS: C
Middle-aged adults also begin to help aging parents while being responsible for their own children, placing them in the sandwich generation. It does not include job and family responsibilities; old habits and new ones; or career and retiring.
A nurse is assessing a middle-aged patient’s barriers to change in eating habits. Which areas will the nurse assess that are external barriers? (Select all that apply.) a. Lack of facilities b. Lack of materials c. Lack of knowledge d. Lack of social supports e. Lack of short- and long-term goals
ANS: A, B, D
External barriers to change include lack of facilities, materials, and social supports. Internal barriers are lack of knowledge, insufficient skills, and undefined short- and long-term goals.
A home health nurse is providing care to a middle-aged couple with children at home. The patient has a debilitating chronic illness. Which areas will the nurse need to assess? (Select all that apply.) a. Adherence to treatment and rehabilitation regimens b. Coping mechanisms of patient and family c. Need for community services or referrals d. Knowledge base of patient only e. Use of a doula for care
ANS: A, B, C
Along with the current health status of the chronically ill middle-aged adult, you need to assess the knowledge base of both the patient and family. In addition, you must determine the coping mechanisms of the patient and family, adherence to treatment and rehabilitation regimens, and the need for community and social services, along with appropriate referrals. A doula is a support person to be present during labor to assist women who have no other source of support.
A nurse is providing prenatal care to a first-time mother. Which information will the nurse share with the patient? (Select all that apply.) a. Regular trend for postpartum depression b. Protection against urinary infection c. Strategies for empty nest syndrome d. Exercise patterns e. Proper diet
ANS: B, D, E
Prenatal care includes a thorough physical assessment of the pregnant woman during regularly scheduled intervals. Information regarding STIs and other vaginal infections and urinary infections that will adversely affect the fetus and counseling about exercise patterns, diet, and child care are important for a pregnant woman. Empty nest syndrome occurs as children leave the home. Postpartum depression is rare.
A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find? a. Lives in a nursing home. b. Lives with a spouse. c. Lives divorced. d. Lives alone.
ANS: B
Recent research found that 59% of older adults in noninstitutional settings lived with a spouse (48% of older women, 72% of older men); 28% lived alone (34% of older women, 20% of older men); and only 3.1% of all older adults resided in institutions such as nursing homes or centers. Most older adults have lost a spouse due to death rather than divorce.
A nurse is developing a plan of care for an older adult. Which information will the nurse consider?
a.
Should be standardized because most geriatric patients have the same needs.
b.
Needs to be individualized to the patient’s unique needs.
c.
Focuses on the disabilities that all aging persons face.
d.
Must be based on chronological age alone.
ANS: B
Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Aging does not automatically lead to disability and dependence. Chronological age often has little relation to the reality of aging for an older adult
Which information presented by a co-worker on a gerontological unit will cause the nurse to intervene?
a.
Most older people have dependent functioning.
b.
Most older people have strengths we should focus on.
c.
Most older people should be involved in care decision.
d.
Most older people should be encouraged to have independence.
ANS: A
Most older people remain functionally independent despite the increasing prevalence of chronic disease; therefore, this misconception should be addressed. It is critical for you to respect older adults and actively involve them in care decisions and activities. You also need to identify an older adult’s strengths and abilities during the assessment and encourage independence as an integral part of your plan of care.
A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are consistent with the nurse’s suspicions? a. Flea bites and lice infestation. b. Left at a grocery store. c. Refuses to take a bath. d. Cuts and bruises.
ANS: A
Neglect is the failure to provide basic necessities such as food, water, shelter, hygiene, and medical care. Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food, water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating, pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and untreated injuries.
A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use?
a.
Provide several topics of discussion at once to promote independence and making choices.
b.
Avoid uncomfortable silences after questions by helping patients complete their statements.
c.
Ask patients to recall past experiences that correspond with their interests.
d.
Speak in a high pitch to help patients hear better.
ANS: C
Teaching strategies include the use of past experiences to connect new learning with previous knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond because older adults’ reaction times are longer than those of younger persons, and keeping the tone of voice low; older adults are able to hear low sounds better than high-frequency sounds.
An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is concerned about the patient’s ability to care for self, especially during this convalescence. What should the nurse do?
a.
Stress that older patients usually ask for help when needed.
b.
Inform the family that placement in a nursing center is a permanent solution.
c.
Tell the family to enroll the patient in a ceramics class to maintain quality of life.
d.
Provide information and answer questions as family members make choices among care options
ANS: D
Nurses help older adults and their families by providing information and answering questions as they make choices among care options. Some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life varies and is unique for each person.
What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center?
a.
Have the family members evaluate nursing home staff according to their ability to get tasks done efficiently and safely.
b.
Make sure that nursing home staff members get patients out of bed and dressed according to staff’s preferences.
c.
Explain that it is important for the family to visit the center and inspect it personally.
d.
Suggest a nursing center that has standards as close to hospital standards as possible.
ANS: C
An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff should focus on the person, not the task. Residents should be out of bed and dressed according to their preferences, not staff preferences.
A 70-year-old patient who is experiencing worsening dementia is no longer able to live alone. The nurse is discussing health care services and possible long-term living arrangements with the patient’s only son. What will the nurse suggest?
a.
An apartment setting with neighbors close by.
b.
Having the patient utilize weekly home health visits.
c.
A nursing center because home care is no longer safe.
d.
That placement is irrelevant because the patient is retreating to a place of inactivity.
ANS: C
Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult or when convalescence from hospitalization requires more assistance than the family is able to provide. An apartment setting and the use of home health visits are not appropriate because living at home is unsafe. Dementia is not a time of inactivity but an impairment of intellectual functioning.
A nurse is caring for an older adult. Which goal is priority? a. Adjusting to career b. Adjusting to divorce c. Adjusting to retirement d. Adjusting to grandchildren
ANS: C
Adjusting to retirement is one of the developmental tasks for an older person. A young or middle-aged adult has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.
A nurse is observing for the common loss in an older-adult patient. What is the nurse assessing? a. Loss of finances through changes in income b. Loss of relationships through death c. Loss of career through retirement d. Loss of home through relocation
ANS: B
The universal loss for older adults usually revolves around the loss of relationships through death. Life transitions, of which loss is a major component, include retirement and the associated financial changes, changes in roles and relationships, alterations in health and functional ability, changes in one’s social network, and relocation. However, these are not the universal loss.
A nurse is discussing sexuality with an older adult. Which action will the nurse take?
a.
Ask closed-ended questions about specific symptoms the patient may experience.
b.
Provide information about the prevention of sexually transmitted infections.
c.
Discuss the issues of sexuality in a group in a private room.
d.
Explain that sexuality is not necessary as one ages.
ANS: B
Include information about the prevention of sexually transmitted infections when appropriate. Open-ended questions inviting an older adult to explain sexual activities or concerns elicit more information than a list of closed-ended questions about specific activities or symptoms. You need to provide privacy for any discussion of sexuality and maintain a nonjudgmental attitude. Sexuality and the need to express sexual feelings remain throughout the human life span.
A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding? a. Oily skin b. Faster nail growth c. Decreased elasticity d. Increased facial hair in men
ANS: C
Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles.
An older-adult patient in no acute distress reports being less able to taste and smell. What is the nurse’s best response to this information?
a.
Notify the health care provider immediately to rule out cranial nerve damage.
b.
Schedule the patient for an appointment at a smell and taste disorders clinic.
c.
Perform testing on the vestibulocochlear nerve and a hearing test.
d.
Explain to the patient that diminished senses are normal findings.
ANS: D
Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is unnecessary at this time as per the information provided.
A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal? a. Disorientation b. Poor judgment c. Slower reaction time d. Loss of language skills
ANS: C
Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require further investigation of underlying causes.
An older patient diagnosed with dementia and confusion is admitted to the nursing unit after hip replacement surgery. Which action will the nurse include in the plan of care? a. Maintain a routine. b. Continue to reorient. c. Allow several choices. d. Socially isolate patient.
ANS: A
Patients experiencing dementia need a routine. Continuing to reorient a patient with dementia is nonproductive and not advised. Patients with dementia need limited choices. Social interaction based on the patient’s abilities is to be promoted.
A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will most likely be assisting the patient with which activity? a. Taking a bath b. Getting dressed c. Making a phone call d. Going to the bathroom
ANS: C
Instrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare meals, or make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and toileting) are essential to independent living.
A male older-adult patient expresses concern and anxiety about decreased penile firmness during an erection. What is the nurse’s best response?
a.
Tell the patient that libido will always decrease, as well as the sexual desires.
b.
Tell the patient that touching should be avoided unless intercourse is planned.
c.
Tell the patient that heterosexuality will help maintain stronger libido.
d.
Tell the patient that this change is expected in aging adults
ANS: D
Aging men typically experience an erection that is less firm and shorter acting and have a less forceful ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of libido. However, for both men and women sexual desires, thoughts, and actions continue throughout all decades of life. Sexuality involves love, warmth, sharing, and touching, not just the act of intercourse. Touch complements traditional sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or possible. Clearly not all older adults are heterosexual, and there is emerging research on older adult, lesbian, gay, bisexual, and transgender individuals and their health care needs.
A patient asks the nurse what the term polypharmacy means. Which information should the nurse share with the patient?
a.
This is multiple side effects experienced when taking medications.
b.
This is many adverse drug effects reported to the pharmacy.
c.
This is the multiple risks of medication effects due to aging.
d.
This is concurrent use of many medications.
ANS: D
Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with side effects, adverse drug effects, or risks of medication use due to aging.
An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the patient correctly understands the teaching on safety concerns?
a.
“I’ll take my time getting up from the bed or chair.”
b.
“I should dim the lighting outside to decrease the glare in my eyes.”
c.
“I’ll leave my throw rugs in place so that my feet won’t touch the cold tile.”
d.
“I should wear my favorite smooth bottom socks to protect my feet when walking around.”
ANS: A
Postural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a correct understanding of this concept. Environmental hazards outside and within the home such as poor lighting, slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs are other factors that can lead to falls. Impaired vision and poor lighting are other risk factors for falls and should be avoided (dim lighting). Inappropriate footwear such as smooth bottom socks also contributes to falls.
A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action will the nurse take?
a.
Review the patient’s list of medications at each visit.
b.
Teach that polypharmacy is to be avoided at all cost.
c.
Avoid information about adverse effects.
d.
Focus only on prescribed medications.
ANS: A
Strategies for reducing the risk for adverse medication effects include reviewing the medications with older adults at each visit, examining for potential interactions with food or other medications, simplifying and individualizing medication regimens, taking every opportunity to inform older adults and their families about all aspects of medication use, and encouraging older adults to question their health care providers about all prescribed and over-the-counter medications. Although polypharmacy often reflects inappropriate prescribing, the concurrent use of multiple medications is often necessary when an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter medications and herbal options.
An older-adult patient has developed acute confusion. The patient has been taking tranquilizers for the past week. The patient’s vital signs are normal. What should the nurse do?
a.
Consider age-related changes in body systems that affect pharmacokinetic activity.
b.
Increase the dose of tranquilizer if the cause of the confusion is an infection.
c.
Note when the confusion occurs and medicate before that time.
d.
Restrict phone calls to prevent further confusion.
ANS: A
Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or exacerbate confusion. Carefully administer drugs used to manage confused behaviors, considering age-related changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time of day or is related to environmental factors, nonpharmacological measures such as making the environment more meaningful, providing adequate light, etc., should be used. Making phone calls to friends or family members allows older adults to hear reassuring voices, which may be beneficial.
Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? a. Confusion b. Presbycusis c. Temperature of 97.9° F d. Death of a spouse 2 months ago
ANS: A
Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Older adults tend to have lower core temperatures. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case.
Which patient statement is the most reliable indicator that an older adult has the correct understanding of health promotion activities?
a.
“I need to increase my fat intake and limit protein.”
b.
“I still keep my dentist appointments even though I have partials now.”
c.
“I should discontinue my fitness club membership for safety reasons.”
d.
“I’m up-to-date on my immunizations, but at my age, I don’t need the influenza vaccine.”
ANS: B
General preventive measures for the nurse to recommend to older adults include keeping regular dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and pneumococcal disease.
A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which psychosocial change does the nurse focus on as a priority? a. Sexuality b. Retirement c. Environment d. Social isolation
ANS: D
The highest priority at this time is the potential for social isolation. This woman does not know how to drive and lives in a rural community that does not have public transportation. All of these factors contribute to her social isolation. Other possible changes she may be going through right now include sexuality related to her advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired for 5 years, so this is also not an immediate need. She may eventually experience needs related to environment, but the data do not support this as an issue at this time.
A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes will the nurse consider when assessing this patient? (Select all that apply.) a. Electrolyte imbalance b. Sensory deprivation c. Hypoglycemia d. Drug effects e. Dementia
ANS: A, B, C, D
Delirium, or a state of acute confusion, is a potentially reversible cognitive impairment that is often due to a physiological event. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or hemorrhage. Sometimes it is also caused by environmental factors such as sensory deprivation or overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional distress. Dementia is a gradual, progressive, and irreversible cerebral dysfunction.
A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration?
a. A 36 year old who is presacribeidrblon.gc-toerm s/tetreoisdtherapy.
b. A 55 year old who recently received intravenous fluids.
ANS: C
c. A 76 year old who is cognitively impaired.
d. An 83 year old with congestive heart failure.
ANS: C
Older adults, because they have less total body water than younger adults, are at greater risk
for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids
independently or cannot make his or her need for fluids known is at high risk for dehydration. The client with heart failure has a risk for both fluid imbalances. Long-term steroids and recent IV fluid administration do not increase the risk of dehydration.
A nurse is caring for an older adult who exhibits dehydration-induced confusion. Which intervention by the nurse is best?
a. Measure intake and output every 4 hours
b. Assess client further for fall risk
c. Increase the IV flow rate to 250 mL/hr
d. Place the client in a high-Fowler’s position
ANS: B
Dehydration most frequently leads to poor perfusion and cerebral hypoxia, causing confusion. The client with dehydration is at risk for falls because of this confusion, orthostatic hypotension , dysrhythmias, and/or muscle weakness. The nurse’s best response is to do a more thorough evaluation of the client’s risk for falls. Measuring intake and output may need to occur more frequently than every 4 hours, but does not address critical need. The nurse would not adjust the IV flow rate without a prescription or standing protocol. For an older adult, this rapid an infusion rate could lead to fluid overload. Sitting the client in a high-Fowler’s position may or may not be comfortable but still does not address the most important issue which is safety.
After teaching a client who is being treated for dehydration, a nurse assesses the client’s understanding. Which statement indicates that the client correctly understood the teaching?
a. “I must drink a quart (liter) of water each day”
b. “I will weigh myself each morning before I eat or drink”
c. “I will use a salt substitute when making and eating my meals”
d. “I will not drink liquids after 6 p.m. so I won’t have to get up at night”
ANS: B
One liter of water weighs 1 kg; therefore, a change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb (0.2 kg) daily is indicative of excess fluid loss. One liter of fluid a day is insufficient. A salt substitute is not related to dehydration. Clients may want to limit fluids after dinner so they won’t have to get up, but this does not address dehydration if the patient drinks the recommended amount of fluid during the earlier part of the day.
A nurse is assessing clients on a medical surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss?
a. Client taking furosemide
b. Anxious client with tachypnea
c. Client who is on fluid restrictions
d. Client who is constipated with abdominal pain
ANS: B
Insensible water loss is water loss through the skin, lungs and stool. Clients at risk for insensible water loss include those being mechanically ventilated, those with rapid respirations, and those undergoing continuous GI suctioning. Clients who have thyroid crisis, trauma burns, states of extreme stress, and fever are also at increased risk. The client taking furosemide will have increased fluid loss, but not insensible water loss. The other two clients on a fluid and with constipation are not at risk for insensible fluid loss.
A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan?
a. Increased respiratory rate from 12 to 22 breaths/min
b. Decreased skin turgor on the client’s posterior hand and forehead
c. Increased urine specific gravity from 1.012 to 1.030 g/mL
d. Decreased orthostatic changes when standing
ANS: D
The focus of management for clients with dehydration is to increase fluid volumes to normal. When blood volume is normal, orthostatic blood pressure and pulse changes will not occur. This assessment finding shows a therapeutic response to treatment. Increased respirations, decreased skin turgor, and higher urine specific gravity all are indicators of continuing dehydration.
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client’s understanding. Which food choice for lunch indicates that the client correctly understood the teaching?
a. Slices of smoked ham with potato salad
b. Bowl of tomato soup with a grilled cheese
c. Salami and cheese on whole-wheat crackers
d. Grilled chicken breast with glazed carrots
ANS: D
Clients on restricted sodium diets generally avoid processes, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The ham, tomato soup, salami and crackers are usually high in sodium.
A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia?
a. A 34 year old who is NPO and receiving rapid intravenous D5W infusions
b. A 50 year old with an infection who is prescribed a sulfonamide antibiotic
c. A 67 year old who is experiencing pain and is prescribed ibuprofen
d. A 73 year old who is experiencing tachycardia who is receiving digoxin
ANS: A
Dextrose 5% in water (D5W) contains no electrolytes. The dextrose is rapidly metabolized when infused, leaving the solution hypotonic. Aggressive ingestion (or infusion) of hypotonic solutions can lead to hyponatremia. Because the client is not taking any food or fluids by mouth, normal sodium excretion can also lead to hyponatremia. The sulfonamide antibiotic, ibuprofen, and digoxin will not put a client at risk for hyponatremia.
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client’s teaching?
a. “Have your spouse watch you for irritability and anxiety”
b. “Notify the clinic if you notice muscle twitching”
c. “Call your primary health care provider for diarrhea”
d. “Bake or grill your meat rather than frying it”
ANS: C
One sign of hyponatremia is diarrhea due to increased intestinal motility. The client would be taught to call the primary health care provider if this is noticed. Irritability and anxiety are common neurological signs of hypokalemia. Muscle twitching is related to hypernatremia. Cooking methods are not a cause of hypernatremia.
A nurse is caring for a client who has the following lab results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first?
a. Depth of respirations
b. Bowel sounds
c. Grip strength
d. Electrocardiography
ANS: A
A client with a low serum potassium level may exhibit hypoactive bowel sounds, cardiac dysrhythmias, and muscle weakness resulting in shallow respirations and decreased handgrips. The nurse would assess the client’s respiratory status first to ensure that respirations are sufficient. The respiratory assessment would include rate and depth of respirations, respiratory effort, and oxygen saturation. The other assessments are important but are secondary to the client’s respiratory status.
A nurse cares for a client who has a serum potassium of 6.5 mWq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first?
a. Prepare to administer patiromer by mouth
b. Provide a healthy heart, low potassium diet
c. Prepare to administer dextrose 20% and 10 units of regular insulin IV push
d. Prepare the client for hemodialysis treatment
ANS: C
A client with a critically high serum potassium level and cardiac changes would be treated immediately to reduce the extracellular potassium level. Potassium movement into the cells is enhanced by insulin by increasing the activity of sodium potassium pumps. Insulin will decreased both serum potassium and glucose levels and therefore would be administered with dextrose to prevent hypoglycemia. Patiromer may be ordered, but this therapy may take hours to reduce potassium levels.. Dialysis may also be needed, but this treatment will take much longer to implement and is not the first intervention the nurse would implement. Decreasing potassium intake may help prevent hyperkalemia in the future but will not decrease the client’s current potassium level.
The nurse is caring for a client who has fluid overload. What action by the nurse takes
priority?
a. Administer high-ceiling (loop) diuretics.
abirb.com/test
b. Assess the client’s lung sounds every 2 hours.
c. Place a pressure-relieving overlay on the mattress.
d. Weigh the client daily at the same time on the same scale.
ANS: B
All interventions are appropriate for the client who is overhydrated. However, client safety is the priority. A client with fluid overload can easily go into pulmonary edema, which can be life threatening. The nurse would closely monitor the client’s respiratory status.
A nurse is assessing a client with hypokalemia, and notes that the client’s handgrip strength
has diminished since the previous assessment 1 hour ago. What action does the nurse take
first?
a. Assess the client’s respiratory rate, rhythm, and depth.
b. Measure the client’s pulse and blood pressure.
c. Document findings and monitor the client.
d. Call the health care primary health care provider.
ANS: A
In a client with hypokalemia, progressive skeletal muscle weakness is associated with
increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment
first to make sure that the client is not in immediate jeopardy. Cardiac dysrhythmias are also
associated with hypokalemia. The client’s pulse and blood pressure would be assessed after
assessing respiratory status. Next, the nurse would call the health care primary health care provider to obtain orders for potassium replacement. Documenting findings and continuing to monitor the client would occur during and after potassium replacement therapy.
A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure?
a. Notifies the pharmacy of the IV potassium order.
b. Assesses the client’s IV site every hour during infusion.
c. Sets the IV pump to deliver 30 mEq of potassium an hour.
d. Double-checks the IV bag against the order with the precepting nurse.
ANS: C
IV potassium should not be infused at a rate exceeding 20mEq/hr under any circumstances. This action shows a need for further knowledge. The other actions are acceptable for this high-alert drug.
A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor
understanding of this condition?
a. Assesses the client’s Chvostek and Trousseau sign.
b. Keeps the client’s room quiet and dimly lit.
c. Moves the client carefully to avoid fracturing bones.
d. Administers bisphosphonates as prescribed
ANS: D
Bisphosphonates are used to treat hypercalcemia. The Chvostek and Trousseau signs are used to assess for hypocalcemia. Keeping the client in a low stimulus environment is important because the excitable nervous system cells are overstimulated. Long-standing hypocalcemia can cause fragile, brittle bones which can be fractured.
A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L).
Which primary health care provider order does the nurse implement first?
a. Encourage oral fluid intake.
b. Connect the client to a cardiac monitor.
c. Assess urinary output.
d. Administer oral calcitonin.
ANS: B
This client has hypercalcemia. Elevated serum calcium levels can decrease cardiac output and
cause cardiac dysrhythmias. Connecting the client to a cardiac monitor is a priority to assess
for lethal cardiac changes. Encouraging oral fluids, assessing urine output, and administering
calcitonin are treatments for hypercalcemia, but are not the highest priority
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital?
a. Ask family members to speak quietly to keep the client calm.
b. Assess urine color, amount, and specific gravity each day.
c. Encourage the client to drink at least 1 L of fluids each shift.
d. Dangle the client on the bedside before ambulating.
ANS: D
An older adult with moderate dehydration may experience orthostatic hypotension. The client needstodangleonthebedsidaebefiorrbea.mcboulmatin/gt.eAslthtoughdehydrationinanolderadultmay cause confusion, speaking quietly will not help the client remain calm or decrease confusion. Assessing the client’s urine may assist with the diagnosis of dehydration but would not
prevent injury. Clients are encouraged to drink fluids, but 1 L of fluid each shift for an older
adult may cause respiratory distress and symptoms of fluid overload, especially if the client has heart failure or renal insufficiency.
A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) a. Increased pulse rate b. Distended neck veins c. Decreased blood pressure d. Warm and pink skin e. Skeletal muscle weakness f. Visual disturbances
ANS: A,B,E,F
Signs and symptoms of fluid overload include increased pulse rate, distended neck veins,
increased blood pressure, pale and cool skin, skeletal muscle weakness, and visual disturbances. Decreased blood pressure would be seen in dehydration. Warm and pink skin is a normal finding.
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion
and release. For which potential complications will the nurse assess? (Select all that apply.)
a. Urine output of 25 mL/hr
b. Serum potassium level of 5.4 mEq/L (5.4 mmol/L)
c. Urine specific gravity of 1.02 g/mL
d. Serum sodium level of 128 mEq/L (128 mmol/L)
e. Blood osmolality of 250 mOsm/kg (250 mmol/kg)
ANS: B,E
Aldosterone is a naturally occurring hormone of the mineralocorticoid type that increases the
reabsorption of water and sodium in the kidney at the same time that it promotes excretion of potassium. Any drug or condition that disrupts aldosterone secretion or release increases the
client’s risk for excessive water loss (increased urine output), increased potassium
reabsorption, decreased blood osmolality, and increased urine specific gravity. The client
would not be at risk for sodium imbalance.
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.)
a. Reports of palpitations
b. Slow, shallow respirations
c. Orthostatic hypotension
d. Paralytic ileus
e. Skeletal muscle weakness
f. Tall, peaked T waves on ECG
ANS: A,E,F
Electrolyte imbalances associated with acute renal failure include hyperkalemia. The nurse would assess for electrocardiogram changes, including tall, peaked T waves, reports of palpitations or “skipped beats,” diarrhea, and skeletal muscle weakness in clients with hyperkalemia. The other choices are potential complications of hypokalemia. Respiratory muscles may be affected with lethally high hyperkalemia.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance?
(Select all that apply.)
a. Hypokalemia—muscle weakness with respiratory depression
b. Hypermagnesemia—bradycardia and hypotension
c. Hyponatremia—decreased level of consciousness
d. Hypercalcemia—positive Trousseau and Chvostek signs
e. Hypomagnesemia—hyperactive deep tendon reflexes
f. Hypernatremia—weak peripheral pulses
ANS: A,B,C,E,F
Hypokalemia is associated with muscle weakness and respiratory depression. Hypermagnesemia manifests with bradycardia and hypotension. Hyponatremia can present
with decreased level of consciousness. Hypomagnesemia can be assessed through hyperactive deep tendon reflexes. Weak peripheral pulses are felt in hypernatremia. Positive Trousseau and Chvostek signs are seen in hypocalcemia.
After administering potassium chloride, a nurse evaluates the client’s response. Which signs and symptoms indicate that treatment is improving the client’s hypokalemia? (Select all that apply.)
a. Respiratory rate of 8 breaths/min
b. Absent deep tendon reflexes
c. Strong productive cough
d. Active bowel sounds
e. U waves present on the electrocardiogram (ECG)
ANS: C, D
A strong, productive cough indicates an increase in muscle strength and improved potassium imbalance. Active bowel sounds also indicate that treatment is working. A respiratory rate of 8 breaths/min, absent deep tendon reflexes, and U waves present on the ECG are all signs and symptoms of hypokalemia and do not demonstrate that treatment is working.
A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client’s care plan? (Select all that apply.)
a. Calculate pulse pressure with each blood pressure reading.
b. Assess skin turgor using the back of the client’s hand.
c. Assess for pitting edema in dependent body areas.
d. Monitor trends in the client’s daily weights
e. Assist the client to change positions frequently
f. Teach client and family how to read food labels for sodium
ANS: A,C,D,E,F
Appropriate interventions for the client who has overhydration include calculating the pulse
pressure with each BP reading as this is a sign of cardiovascular involvement, assessing for pitting edema in the client’s dependent body areas, monitoring trends in the client’s daily weight as fluid retention is not always visible, protecting the client’s skin by helping him or
her change positions, and teaching the client and family to read food labels some type of sodium restriction may be required at home. The nurse assesses skin turgor on the chest or forehead.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.)
a. Hypomagnesemia—kidney failure
b. Hyperkalemia—salt substitutes
c. Hyponatremia—heart failure
d. Hypernatremia—hyperaldosteronism
e. Hypocalcemia—diarrhea
f. Hypokalemia—loop diuretics
ANS: B,C,D,E,F
Salt substitutes contain potassium and are a cause of hyperkalemia. Hyponatremia can be caused by heart failure with fluid overload. Hyperaldosterone is a cause of hypernatremia and diarrhea causes actual calcium deficits. Loop diuretics excrete potassium. Decreased kidney function is a cause of magnesium excess, not deficit.
A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are
paired with the correct potential imbalance? (Select all that apply.)
a. Sodium: 160 mEq/L (mmol/L): Overhydration
b. Potassium: 5.4 mEq/L (mmol/L): Dehydration
c. Osmolarity: 250 mOsm/L: Overhydration
d. Hematocrit: 68%: Dehydration
e. BUN: 39 mg/dL: Overhydration
f. Magnesium: 0.8 mg/dL: Dehydration
ANS: B,C,D,F
In dehydration, hemoconcentaratbioinrubsu.aclloy rmesu/ltseinshtigher levels of hemoglobin, hematocrit, serum osmolarity, glucose, protein, blood urea nitrogen, and electrolytes. The opposite is true of overhydration. The sodium level is high, indicating dehydration. The potassium level is high, also indicating possible dehydration. The osmolarity is low, indicating overhydration,
the hematocrit is high indicating dehydration, the BUN is high indicating dehydration, and the magnesium level is low, indicating possible dehydration and malnutrition from
diarrhea-causing diseases.
A nurse assesses a client with diabetes mellitus who is admitted with an acid–base imbalance. The client’s arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L (18 mmol/L). Which sign or symptom does the nurse identify as an example of the client’s compensatory mechanisms?
a. Increased rate and depth of respirations
b. Increased urinary output
c. Increased thirst and hunger
d. Increased release of acids from the kidneys
ANS: A
This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are signs and symptoms of hyperglycemia but are not compensatory mechanisms for acid–base imbalances. The kidneys do not release acids.
A nurse assesses a client who is experiencing an acid–base imbalance. The client’s arterial blood gas values are pH 7.2, PaO2 88 mmHg, PaCO2 38 mmHg, and HCO3 19mEq/L (19 mmol/L). Which assessment would the nurse perform first?
a. Cardiac rate and rhythm
b. Skin and mucous membranes
c. Musculoskeletal strength
d. Level of orientation
ANS: A
Early cardiovascular changes for a client experiencing moderate acidosis include increased heart rate and cardiac output. As the acidosis worsens, the heart rate decreases and electrocardiographic changes will be present. The nurse responds by performing a thorough cardiovascular assessment. Changes will occur in the integumentary system, musculoskeletal system, and neurological system, but assessing for the cardiovascular complications comes first.
A nurse assesses a client who is prescribed furosemide for hypertension. For which acid–base
imbalance does the nurse assess to prevent complications of this therapy?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis
ANS: D
Many diuretics, especially loop and thiazide diuretics, increase the excretion of hydrogen ions, leading to excess acid loss through the renal system. This situation is an actual acid deficit.
A nurse is caring for a client who is experiencing moderate metabolic alkalosis. What action
would the nurse take?
a. Monitor daily hemoglobin and hematocrit values
b. Administer furosemide intravenously.
c. Encourage the client to take deep breaths.
d. Teach the client fall prevention measures.
ANS: D
The most important nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Client’s with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.
A nurse is assessing a client who has acute pancreatitis and is at risk for an acid–base imbalance. For which manifestation of this acid–base imbalance would the nurse assess?
a. Agitation
b. Kussmaul respirations
c. Seizures
d. Positive Chvostek sign
ANS: B
The pancreas is a major site of bicarbonate production. Pancreatitis can cause metabolic acidosis through underproduction of bicarbonate ions. Signs and symptoms of acidosis include lethargy and Kussmaul respirations. Agitation, seizures, and a positive Chvostek sign are signs and symptoms of the electrolyte imbalances that accompany alkalosis.
A nurse assesses a client who is admitted with an acid–base imbalance. The client’s arterial blood gas values were pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L (16 mmol/L). The most recent blood gasses show a drop in the pH. What action does the nurse take next?
a. Assess client’s rate, rhythm, and depth of respiration.
b. Measure the client’s pulse and blood pressure.
c. Document the findings and continue to monitor.
d. Notify the primary health care provider.
ANS: A
Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiacmonitoring. Findings would be documented, but simply continuing to monitor is not sufficient. Before notifying the primary care provider, the nurse must have more data to report.
A nurse is caring for a client who has the following arterial blood values: pH 7.12, PaO2 56 mm Hg, PaCO2 65 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which clinical situation does the nurse correlate with these values?
a. Diabetic ketoacidosis in a person with emphysema
b. Bronchial obstruction related to aspiration of a hot dog
c. Anxiety-induced hyperventilation in an adolescent
d. Diarrhea for 36 hours in an older, frail woman
ANS: B
Arterial blood gas values indicate that the client has acidosis with normal levels of
bicarbonate, suggesting that the problem is not metabolic. Arterial concentrations of oxygen
and carbon dioxide are abnormal, with low oxygen and high carbon dioxide levels. Thus, this client has respiratory acidosis from inadequate gas exchange. The fact that the bicarbonate level is normal indicates that this is an acute respiratory problem rather than a chronic problem, because no renal compensation has occurred. The client who would have these ABG values is the one with the new onset of airway obstruction.
A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The client’s arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L (22 mmol/L). What action would the nurse take first?
a. Apply oxygen by mask or nasal cannula.
b. Apply a paper bag over the client’s nose and mouth.
c. Administer 50 mL of sodium bicarbonate intravenously.
d. Administer 50 mL of 20% glucose and 20 units of regular insulin.
ANS: A
This client is severely hypoxic and needs oxygen. Now that the seizure has ended, the client can breathe again normally, so oxygen administration will rapidly increase the PaO2. Rebreathing carbon dioxide with a paper bag would make the acidosis worse. Bicarbonate is only indicated with extremely low pH and serum bicarbonate levels. Glucose and insulin are administered to decrease the high potassium levels associated with acidosis, but this situation should reverse itself with oxygen and breathing.
After teaching a client who was malnourishing and is being discharged, a nurse assesses the client’s understanding. Which statement indicates that the client correctly understood teaching to decrease risk for the development of metabolic acidosis?
a. “I will drink at least three glasses of milk each day.”
b. “I will eat three well-balanced meals and a snack daily.”
c. “I will not take pain medication and antihistamines together.”
d. “I will avoid salting my food when cooking or during meals.”
ANS: B
Starvation or a diet with too few carbohydrates can lead to metabolic acidosis by forcing cells metabolism. Eating sufficient calories from all food groups helps reduce this risk. Milk, taking pain medications with antihistamines, and salting food are not related.
A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm
Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which client condition does the nurse correlate with these results?
a. Diarrhea and vomiting for 36 hours
b. Anxiety-induced hyperventilation
c. Chronic obstructive pulmonary disease (COPD)
d. Diabetic ketoacidosis and emphysema
ANS: B
The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the
oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic acidosis and COPD would lead to respiratory acidosis. The client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.
After providing discharge teaching, a nurse assesses the client’s understanding regarding increased risk for metabolic alkalosis. Which statement indicates that the client needs additional teaching?
a. “I don’t drink milk because it gives me gas and diarrhea”
b. “I have been taking digoxin every day for the last 15 years.”
c. “I take sodium bicarbonate after every meal to prevent heartburn.”
d. “In hot weather, I sweat so much that I drink six glasses of water each day.”
ANS: C
Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.
A nurse is caring for a client who is experiencing excessive diarrhea. The client’s arterial blood gas values are pH 7.18, PaO2 98 mm Hg, PaCO2 45 mm Hg, and HCO3 16 mEq/L (16 mmol/L). Which primary health care provider order does the nurse expect to receive?
a. Furosemide 40 mg
b. Sodium bicarbonate
c. Mechanical ventilation
d. Indwelling urinary catheter
ANS: B
This client’s arterial blood gas values represent metabolic acidosis related to a loss of bicarbonate ions from diarrhea. The bicarbonate would be replaced to help restore this client’s acid–base balance as the pH is below 7.2 and the bicarbonate level is low. Furosemide would cause an increase in acid fluid and acid elimination via the urinary tract; although this may improve the client’s pH, the client has excessive diarrhea and cannot afford to lose more fluid. Mechanical ventilation is used to treat respiratory acidosis for clients who cannot keep their oxygen saturation at 90%, or who have respiratory muscle fatigue. Mechanical ventilation and an indwelling urinary catheter would not be prescribed for that client.
A nurse evaluates a client’s arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L (22 mmol/L). Which intervention does the nurse implement first?
a. Assess the airway.
b. Administer prescribed bronchodilators.
c. Provide oxygen.
d. Administer prescribed mucolytics.
ANS: A
All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.
