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A nurse is assisting with the admission of a client who is hyperventilating, reports lightheadedness and paresthesias, and has blurred vision and a new onset of confusion. The nurse should suspect that the client has developed which of the following imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The correct answer is D, respiratory alkalosis. Hyperventilation causes excessive loss of carbon dioxide, leading to respiratory alkalosis. This is evidenced by lightheadedness, paresthesias, blurred vision, and confusion due to decreased carbon dioxide levels in the blood. Metabolic acidosis (A) is characterized by low pH and bicarbonate levels, not seen in this scenario. Metabolic alkalosis (B) is due to excess bicarbonate, which is not present in hyperventilation. Respiratory acidosis (C) is caused by retention of carbon dioxide, opposite of what is seen in hyperventilation.
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A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, 'I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.' The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?
- A. Bargaining
- B. Denial
- C. Depression
- D. Anger
Correct Answer: B
Rationale: The correct answer is B: Denial. The client's statement indicates denial as they are refusing to accept the reality of their condition and are hopeful that their kidneys are functioning again, despite the need for dialysis. This stage in Kübler-Ross's stages of grieving involves avoiding the truth to cope with the overwhelming emotions. Bargaining (A), Depression (C), and Anger (D) are not demonstrated in the client's statement. Bargaining involves seeking alternatives to the situation, Depression involves feelings of sadness and hopelessness, and Anger involves frustration and resentment.
A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?
- A. Non-palpable spleen
- B. Slightly moist skin
- C. Presence of surface papillae on tongue
- D. Depigmented hair
Correct Answer: D
Rationale: The correct answer is D: Depigmented hair. Malnutrition can lead to changes in hair color and texture, resulting in depigmented or thinning hair. This is due to the body lacking essential nutrients needed for healthy hair growth. Non-palpable spleen (A) is not typically associated with malnutrition. Slightly moist skin (B) is more likely to be seen in a well-nourished individual. Presence of surface papillae on the tongue (C) is not a common manifestation of malnutrition. Therefore, depigmented hair (D) is the most likely manifestation of malnutrition in this scenario.
A nurse is caring for a client who is to undergo surgery the next day. The client tells the nurse, 'I'm afraid of what's going to happen.' Which of the following responses should the nurse make?
- A. Assure the client that the surgery is safe and complications are rare.
- B. Encourage the client to discuss her fears further.
- C. Inform the client that she has an excellent provider and has nothing to worry about.
- D. Explain to the client that anxiety can prolong hospitalization.
Correct Answer: B
Rationale: Encouraging the client to talk about their fears provides emotional support and can reduce anxiety.
A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
- A. Pain
- B. Hearing loss
- C. The client's culture
- D. Motor impairment
Correct Answer: A
Rationale: The correct answer is A: Pain. Pain can significantly impair a client's ability to concentrate and retain information during a teaching session. It may cause distress and make it difficult for the client to focus on the instructions provided. Therefore, addressing the pain as a priority before proceeding with teaching is crucial for effective learning.
Hearing loss (B), the client's culture (C), and motor impairment (D) can also present barriers to learning, but these can be accommodated through appropriate communication methods and cultural sensitivity. However, pain directly affects the client's cognitive function and must be managed before effective teaching can take place.
A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. As individuals age, there is a natural decline in muscle mass known as sarcopenia. This is due to a decrease in muscle fiber size and number. The nurse should include this alteration in the presentation because it is a common age-related musculoskeletal change that can lead to weakness, decreased mobility, and increased risk of falls in older adults.
Choices B, C, and D are incorrect because thickened vertebral disks, decreased chest width, and increased force of isometric contractions are not typical age-related musculoskeletal changes. Thickened vertebral disks are more associated with degenerative disc disease, decreased chest width is not a common age-related change, and increased force of isometric contractions is not a typical alteration seen in older adults.