The nurse is preparing to admit a client who has been diagnosed with respiratory alkalosis secondary to a severe anxiety disorder
Which of the following assessment data by the nurse would suggest that the client's condition is deteriorating? 1. Decreased rate of respirations
2. Increased level of consciousness
3. Positive Chvostek's sign
4. Positive Moro response
3. Positive Chvostek's sign
Rationale:
The client with respiratory alkalosis should be monitored for signs of tetany as an indication of a deteriorating condition. A positive Chvostek's sign would indicate that the client's calcium levels are dropping and the client might have tetany. The client with alkalosis will have a decreased level of consciousness and increased respiratory rate. The Moro response is a method of assessing the newborn's startle reflex.
You might also like to view...
A nurse discusses inpatient hospice with a client and the client's family. A family member expresses concern that her loved one will receive only custodial care. How should the nurse respond?
a. "The goal of palliative care is to provide the greatest degree of comfort possible and help the dying person enjoy whatever time is left." b. "Palliative care will release you from the burden of having to care for someone in the home. It does not mean that curative treatment will stop." c. "A palliative care facility is like a nursing home and costs less than a hospital because only pain medications are given." d. "Your relative is unaware of her surroundings and will not notice the difference between her home and a palliative care facility."
The labor and delivery nurse is reviewing charts. Of which client should the nurse inform the supervisor?
1. Multip at 5 cm requesting labor epidural analgesia 2. Primip whose cervix remains at 6 cm for four hours 3. Multip who has developed nausea and vomiting 4. Primip requesting her partner to stay with her
The nurse is caring for a client with acute respiratory acidosis and notes the client's rate and depth of breathing are increased. What is the nurse's understanding of the cause of this finding?
A) Respiratory muscles increase the force of contraction with excess hydrogen levels in the blood. B) The diaphragm weakens with excess hydrogen levels in the blood. C) As the pH increases, the respiratory rate increases. D) As the carbon dioxide level decreases, the respiratory rate increases.
Identify at least four risk factors throughout the procedure that may have contributed to an incorrect count
You are waiting for a patient booked for a routine laparoscopic cholecystectomy late in the afternoon. As you commence your surgical count with the circulating nurse, the surgeon arrives and tells you about his requirements. After this interruption, you complete the count and the surgery commences. Subsequently, in response to uncontrolled bleeding, the surgeon converts to an open procedure. Your circulating nurse has opened additional instruments and accountable items and you remain focused for some time on the surgical count and check of instruments. After 3 hours of surgery, the closure commences and you discover a discrepancy in the count. What will be an ideal response?