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1. Question
A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?
Correct
Answer: Option 3 is the correct answer.
Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.
Test-Taking Strategy: Focus on the subject, clinical manifestations associated with respiratory acidosis, and use knowledge of the signs and symptoms of respiratory acidosis to answer this question. Eliminate options 2 and 4 first because they are comparable or alike and address a decreased respiratory rate. Remember that headache, restlessness, and confusion occur in respiratory acidosis.
Incorrect
Answer: Option 3 is the correct answer.
Rationale: When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.
Test-Taking Strategy: Focus on the subject, clinical manifestations associated with respiratory acidosis, and use knowledge of the signs and symptoms of respiratory acidosis to answer this question. Eliminate options 2 and 4 first because they are comparable or alike and address a decreased respiratory rate. Remember that headache, restlessness, and confusion occur in respiratory acidosis.
The respiratory system functions primarily to maintain the exchange of oxygen and carbon dioxide in the lungs and tissues and to regulate acid-base balance. Any change in this system affects every other body system. Conversely, changes in other body systems may reduce the lungs’ ability to provide oxygen and eliminate carbon dioxide.
Acidosis is caused by an overproduction of acid in the blood or an excessive loss of bicarbonate from the blood (metabolic acidosis) or by a buildup of carbon dioxide in the blood that results from poor lung function or depressed breathing (respiratory acidosis).
