Critical Care and Mental Health Flashcards
The nurse in the ICU is taking a client’s CVP. All of the following are appropriate actions of the nurse when taking a CVP reading, except:
A. Placing the client supine with the head of the bed elevated to no more than 45°
B. Placing the transducer at the fifth intercostal space, mid-axillary line.
C. Placing the transducer at the fourth intercostal space, mid-axillary line.
D. Instruct the client to relax, not strain or cough during the reading.
Explanation
Choice B is correct. This is an inappropriate action. The zero points on the transducer need to be at the level of the right atrium, which is located at the fourth intercostal space, midaxillary line, not at the 5th ICS.
Choices A, C, and D are incorrect. These are appropriate actions. The client should be lying supine with the head of the bed elevated to no more than 45 degrees for the most accurate reading ( Choice A). The zero points on the transducer need to be at the level of the right atrium, which is located at the fourth intercostal space, midaxillary line ( Choice C). This is also referred to as the “Phlebostatic” axis. The client should be instructed to relax, not strain, cough, or do any activity that increases intrathoracic pressure, which causes falsely high measurements ( Choice D).
Your client is a 50-year-old man who sustained an air embolism after the placement of a central venous catheter. You realize the patient was not properly positioned during the procedure. Which of the following could have prevented this incident from happening? **IMAGE CHOICES** A. IMAGE OF SUPINE POSITION B. IMAGE OF PRONE POSITION C. IMAGE OF TRENDELENBURG POSITION D. IMAGE OF FOWLER'S POSITION
Correct Answer is C. This picture shows the Trendelenburg position. In this position, the body is laid supine, or flat on the back on a 15-30 degree incline with the feet elevated above the head. This position is used to prevent air embolism during central venous cannulation. When placing and removing central venous catheters, the CVP should be raised (to decrease the pressure gradient) by placing the patient in the Trendelenburg position. It should also be ensured that patients are adequately hydrated to prevent hypovolemia and to increase CVP.
Trendelenburg position is also used to increase the venous blood return to heart when a client is affected with hypotension, hypovolemia or shock.
Choice A is incorrect. This image represents a Supine position.
Choice B is incorrect. This image represents a Prone position.
Choice D is incorrect. This image represents a Fowler’s position in which the head of the bed is elevated at 45 to 60 degrees angle.
A 45-year old male presents to the emergency department with severe diaphoresis, nausea, shortness of breath, and left-sided neck and chest pain that started 30 minutes prior while doing yard work. What actions should the triage nurse perform immediately for this patient? Select all that apply.
A. Start an IV and obtain a troponin
B. Call the cardiologist
C. Administer 325 mg aspirin
D. Give 1 tablet of sublingual nitroglycerin
E. Inquire about previous cardiac history
F. Perform an EKG
Explanation
A, C, D, E, and F are correct. This patient is experiencing subtle signs that could be indicative of myocardial infarction.
Starting an IV and obtaining a troponin ( Choice A) is especially crucial for the future administration of drugs and assessing the chemical damage done to the heart.
Drugs that could be ordered by the physician if the patient is having an MI are heparin, ticagrelor ( Brilinta), and aspirin. Administering 325 mg aspirin (Choice C) is a gold standard for angina management due to its blood-thinning effects and minimal side effects.
Nitroglycerin ( Choice D) is also essential to administer to a patient with angina, as long as the patient’s blood pressure is above 100/60. This medication allows the blood vessels to dilate ( reduces preload), which will allow more blood flow to the heart.
Asking about previous cardiac history ( Choice E) is essential in obtaining further information about this patient. This will help evaluate the patient’s cardiac risk and the risk of having an acute event now.
Performing an EKG (Choice F) is essential because it will allow the emergency physician to diagnose the patient with a STEMI or NSTEMI and the right treatment.
B is incorrect because calling the cardiologist would be premature at this point. The emergency department physician will evaluate the EKG for any changes and contact the cardiologist if necessary. Calling the cardiologist down to the emergency department is essential if there are elevations in ST or elevation in troponin levels.
While working in the cardiac intensive care unit, you are assessing a patient with left-sided heart failure. A sign off report from the prior shift indicates that the client’s cardiac output has dropped to 2 L/min. Which of the following assessment findings do you expect in the patient? Select all that apply.
A. Crackles
B. Decreased urine output
C. +3 bounding pulses
D. Irritability
Choices A and B are correct. Normal cardiac output in a healthy adult is between 4 liters/ minute (L/min) and 8 L/min. An output of 2L/min exhibited by this client is, therefore, low. A decreased cardiac output manifests with certain clinical signs and symptoms, some of which may be fatal. Lower cardiac output leads to hypotension, pulmonary congestion, and fluid overload.
You would expect the lungs of a patient with poor cardiac output to sound wet. Crackles, rales, and rhonchi (Choice A) are all adventitious breath sounds that you might expect to hear when there is fluid overload. This is due to poor perfusion, and blood backing up in the lungs due to poor function of the left ventricle. Extra fluid will build up causing these ‘wet’ lung sounds.
Decreased urine output (Choice B) is a classic sign of decreased cardiac output. When the cardiac output is decreased, there is decreased perfusion to the rest of the organs of the body. With less perfusion to the kidneys, the glomerular filtration rate falls, which leads to decreased urinary output. Successful treatment of congestive heart failure involves maintaining adequate negative fluid balance (output greater than input).
Choice C is incorrect. You would expect to find weak pulses in your client with decreased cardiac output, not +3 bounding pulses. When the cardiac output is decreased, there is decreased perfusion to the rest of the organs of the body. With decreased perfusion to the peripheries, and the left ventricle not pumping as hard, the pulses will feel weak and thready.
Choice D is incorrect. You would expect your patient with decreased cardiac output to have a decrease in their level of consciousness, such as lethargy, not irritability. This is due to decreased perfusion to the brain. The consequent decrease in oxygen delivery to the brain results in a decreased level of consciousness.
You are the nurse working in the Coronary Care Unit of the hospital. You are assessing the patient who is alert and oriented, respirations 12 and non-labored, and pulse rate 84 and regular. You look up at the monitor and see this rhythm (See Exhibit)
Your first intervention is to:
A. Start CPR.
B. Connect the patient to the defibrillator.
C. Begin ventilations with a bag-valve-mask device.
D. Check to ensure the monitor leads are connected to the patient.
Explanation
Correct Answer: D.
Check to ensure the monitor leads are connected to the patient. Although this rhythm looks like asystole, the fact that the patient is awake and talking to you with a palpable pulse of 84 would indicate that he is probably disconnected from the cardiac monitor. If you determined that the patient was pulseless and unresponsive, you would first start CPR since that would be an indication that the patient is in asystole. Ventilations and a defibrillator are not necessary for this stable patient.
The client in a psychiatric clinic tells the nurse, “I want to kill my wife. The moment I see her, I am going to kill her.” What should be the nurse’s next action?
A. Respect the client’s right to privacy and confidentiality.
B. Document the client’s statements.
C. Notify the client’s psychiatrist of the comments.
D. Explore the client’s feelings about his wife.
Explanation
C is correct. Mental health staff must report identifiable third parties of threats made by a person, even if these threats were discussed in a private therapy session.
A is incorrect. Although the nurse should respect the confidentiality of the subject, the nurse should make arrangements so that the wife is informed of the threat to her safety.
B is incorrect. The nurse needs to document what the client said in the conversation; however, the nurse should implement measures to ensure the safety of the client’s wife.
D is incorrect. Exploring the client’s feelings regarding his wife would further increase the client’s anger toward her. This is not an appropriate action for the nurse to take.
A 78-year older man is admitted with sepsis. Which of the following should the nurse suspect the doctor to order?Select all that apply
A. Crystalloids
B. Blood cultures
C. Abdominal xray
D. Antibiotics
E. Two large-bore IV’s
F. Vasopressors if shock persists
Explanation
Choices A, B, D, E, and F are correct. When treating sepsis, inserting intravenous access (2 large-bore IVs, 16-gauge), obtaining blood cultures, and starting crystalloid fluids are important initial interventions. Vasopressors are administered if the shock persists despite the initial interventions and aggressive fluid resuscitation.
Intravenous access: When sepsis is suspected, adequate venous access with two large-bore IVs (16-gauge) (Choice E) must be placed as soon as possible. This allows the administration of aggressive volume resuscitation (crystalloids) and broad-spectrum antibiotics.
Blood cultures: Blood cultures (Choice B) must be obtained once the sepsis is suspected. Blood cultures help to confirm sepsis diagnosis, identify the causative organism, and tailoring the antibiotic coverage. Per Surviving Sepsis Campaign guidelines, at least 2 blood cultures should be obtained before initiation of antibiotics (one percutaneously drawn and the other from peripheral vascular access.)
Crystalloids: Sepsis often results in systemic inflammatory response syndrome and leads to systemic vasodilation. Isotonic fluids (crystalloids such as normal saline, Choice A) are given intravenously to help maintain systemic vascular resistance (SVR) and blood pressure.
Antibiotics: Antibiotics (Choice D) must be given early to improve the outcomes in Sepsis. Guidelines mandate starting antibiotics within 1 hour of suspected sepsis diagnosis. Initially, empiric broad-spectrum antibiotics are used, but they are later tailored to the specific organism identified on blood cultures.
Vasopressors: Initial intervention in all cases of sepsis includes aggressive volume resuscitation (crystalloid fluid bolus of 30 mL/kg (1-2 L) over 30-60 minutes). If the hypotension persists despite aggressive volume resuscitation with several liters (4 or more liters) of the isotonic crystalloid solution, vasopressors are indicated. Persistent hypotension (shock) is defined as systolic blood pressure lower than 90 mm Hg or Mean Arterial Pressure (MAP) lower than 65 mm Hg with decreased tissue perfusion. When vasopressors are indicated, a central venous catheter should be placed in the internal jugular or subclavian vein. While helpful in administering large volume crystalloids and adequate vasopressors, central venous access also allows measurement of central venous pressure (CVP). Preferred vasopressor in sepsis is Norepinephrine. Dopamine increases heart rate and is not the preferred vasopressor and is only used if there is concomitant bradycardia.
Choice C is incorrect. There is no indication to perform an abdominal x-ray in all cases of sepsis. However, if an abdominal source of infection (abdominal perforation or peritonitis, or bowel obstruction) is suspected, an abdominal X-ray should be obtained.
The nurse is caring for a client with systolic heart failure. Which of the following heart sounds would the nurse expect to auscultate?Select all that apply.
A. S1
B. S2
C. S3
D. S4
Explanation
Correct answers are A, B, and C.
S1 (Choice A) and S2 (Choice B) are normal heart sounds. These normal heart sounds would still be auscultated in a patient with heart failure.
S1 is a good heart sound caused by the closure of the mitral and tricuspid valves. S2 is a good heart sound produced by the closure of the aortic and pulmonic valves.
S3 (“ventricular gallop”) and S4 (“atrial gallop”) are abnormal heart sounds that can be auscultated in heart failure. Bot these heart sounds are low pitched and best heard at the apex with the patient in the left lateral decubitus position. While S3 may sometimes be heard in healthy hearts (normal in children, pregnant women, trained athletes), S4 is almost always abnormal. While S3 is a sign of Systolic heart failure, S4 is heard in Diastolic heart failure.
It is essential to understand these two types of congestive heart failure (CHF) before we proceed to discuss how S3 and S4 are produced.
Systolic CHF: This occurs mainly due to impairment in the contractile function of the left ventricle. Ejection fraction (fraction of the blood pumped out of the left ventricle during the systole) is decreased in Systolic CHF. The left ventricle is usually very compliant (comfortable relaxation). This is seen with ischemic or dilated cardiomyopathy. Diastolic CHF: This occurs mainly due to impairment in the relaxation function of the left ventricle. Ejection fraction (fraction of the blood pumped out of the left ventricle during the systole) is standard in Diastolic CHF. The left ventricle is usually stiff/ non-compliant (does not relax enough to accommodate blood coming out of the atrium during the diastole). This is seen with hypertensive cardiomyopathy where there is Left Ventricular Hypertrophy (LVH).
The nurse would expect to hear an S3 heart sound (Choice C) in her patient with systolic heart failure. S3 occurs after S2 with the opening of the mitral valve, and a passive flow makes the music of a large amount of blood hitting a compliant left ventricle. This large amount of blood hitting the left ventricle is because of the underlying fluid volume overload seen with systolic heart failure.
Choice D is incorrect. The nurse would not expect to hear an S4 heart sound in her patient with systolic heart failure. This is seen in diastolic heart failure. S4 occurs before S1 when the atria contract to actively force blood into the left ventricle. A stiff, non-compliant left ventricle causes it. When the atrial contraction forces blood through the mitral valve, the force is increased due to resistance offered by a stiff ventricle – in this scenario, S4 is caused by the blood striking the left ventricle. S4 heart sound can also be heard in active ischemia. Please note that if a patient is having atrial fibrillation and atria are not contracting, it is impossible to have an S4 heart sound.
A panicked mother brings her 8-year old son into the clinic after noticing that he will not eat. The patient only wants to drink water and is continuously urinating. After seeing that the patient’s blood sugar level of 657 mg/dL, the nurse prepares to insert an IV. Which of the following critical assessment findings should concern the nurse?
A. Listlessness
B. Headache
C. Dry mouth
D. Frequent urination
Explanation
A is the correct answer. This patient is experiencing diabetic ketoacidosis. “Listlessness” refers to decreased level of alertness, lassitude, or lethargy. If this patient is not entirely responsive or responding at all, he may be headed towards a diabetic coma. In that case, further assessments should be performed, such as airway, breathing, and circulation, along with hyperglycemia precautions.
B is incorrect. Hyperglycemia may cause the patient to have a headache, but this is not the most concerning symptom.
C is incorrect. Hyperglycemia can cause dry mouth, frequent urination, fruity breath, abdominal pain, nausea/vomiting, weakness, confusion, and shortness of breath. Dry mouth is not the most concerning symptom.
D is incorrect. Frequent urination is one of the symptoms of hyperglycemia and can be an excellent indicator to lead to a diagnosis. However, confusion and listlessness should be the most concerning symptom at this time.
A patient that has suffered a third-degree burn injury a few hours ago involving 27% of Total Body Surface Area (TBSA) a few hours ago has been rushed to the emergency room. Which of the following should the nurse expect to find in this patient? Select all that apply.
A. Hyponatremia
B. Hyperkalemia
C. Hypotension
D. Increased urinary output
E. Severe Hypophosphatemia
F. Edema in burned areas.
Explanation
Correct answers are Choices A, B, C, and F.
The client has suffered a significant burn. A burn penetrating from the epidermis to the dermis and down into the subcutaneous tissue is classified as a third-degree or full-thickness burn (they grasp the full thickness of the skin). A full-thickness wound involving 10% or greater of Total Body Surface Area (TBSA) or a partial thickness burn involving 25% or greater of TBSA is considered a significant injury.
A nurse involved in the care of the burn patient must be aware of fluid and electrolyte imbalances so the client can be monitored accordingly. Electrolyte and fluid imbalances vary depending on three periods of time since the initial burn injury.
I. Initial resuscitation period: This refers to a period between 0 to 36 hours from the time of burn injury. Due to the damage to the tissues and vessels in major burns, capillary/ vascular permeability is significantly increased, and fluid and electrolyte shifts occur between the body compartments.
Significant edema in the burn area occurs due to fluid accumulation in the burned tissues due to increased vascular permeability and increased interstitial osmotic pressure. (Choice F) Due to changes in cellular permeability, sodium ions enter the cellular compartment resulting in low levels of intravascular sodium (Hyponatremia, Na < 135 mEq/L) (Choice A). Extensive tissue necrosis and cell lysis in major burns also lead to the exit of potassium ions from the cell into the intravascular compartment resulting in Hyperkalemia (K > 5.1 mEq/L). (Choice B). Restoring sodium losses by using appropriate fluid and correcting severe hyperkalemia is necessary during this period. The body’s initial response in a major burn is to shunt blood toward the brain and heart and away from peripheral vasculature and other organs, resulting in a low circulating volume leading to (Choice C). This often manifests with reduced urinary output, not increased urinary output (Choice D is incorrect). Hypotension progresses to shock and organ failure if fluid resuscitation is not accomplished immediately. The goals of fluid resuscitation in an adult are to maintain an adequate urinary output of 30 to 50 cc/hr. Fluid resuscitation is crucial – under-resuscitation can be life-threatening due to shock. Over resuscitation may lead to compartment syndrome. So, the nurse needs to understand and calculate fluid deficits based on the accepted formulas. For fluid resuscitation, modified Brooke formula or Parkland formula is used to calculate the amount of the fluid the client is going to need during the first 24 hours. Lactated Ringer’s solution is the fluid of choice in resuscitating burn patients because of its close resemblance to the body's extracellular fluid composition. The liquid is often warmed to prevent hypothermia—no colloids in the first 24 hours. Modified Brooke formula is 2mls x Total body surface areas burned (TBSA) x total kg body weight. Parkland formula is 4mls x % Total body surface areas burned (TBSA) x total kg weight. The nurse should be aware of the “Rule of 9s” to calculate the TBSA. Both formulas will give an estimate of the first 24-hour fluid requirements from the time of the burn, with half the amount given in the early 8 hours and the remaining half given over the next 16 hours.
II.Early post-resuscitation period: Refers to the period from day 2 to day six from the time of burn injury. This phase is characterized by hypernatremia, hypokalemia, hypocalcemia, hypomagnesemia, and Fluid shifts back to intracellular and intravascular compartments. Shock improves, blood pressure is restored to normal. It is important to remember that with successful resuscitation and resolution of burn shock, one will see the opposite effects in an intravascular compartment about Sodium ( Hypernatremia, Na > 145 mEQ/L)) and Potassium ( Hypokalemia K< 3.5Meq/L) compared to those seen in Initial phase. Increased urinary output (diuretic phase) is seen in this period, not in the first 24 hours (Choice D is incorrect). Urine output may rise to 100cc/hr. D51/2NS is the usual fluid of choice to correct hypernatremia and fluid imbalances during this second phase post burn injury. Severe hypophosphatemia (phosphate less than 1 mg/dl) may appear around day three post-burn and is most prevalent on day 7. It is not seen in a few hours post-burn. (Choice E is incorrect).
III. Inflammation-infection period (also known as the hypermetabolic period) seen after the first week and lasts until wounds are healed– Nutritional support, rehabilitation, and prevention of infection are crucial during this phase.
The nurse is attending a newly admitted client with alcohol withdrawal. Place the following components of alcohol withdrawal in the order the nurse would expect to see them occur. Hyperthermia Mild tremors Hallucinations Delirium Tremens
Correct Answer is: Mild tremors Hyperthermia Hallucinations Delirium Tremens
You are assessing a 16-year-old woman with Anorexia Nervosa. Which of the following symptoms and signs would you expect to find? Select all that apply.
A. Lanugo
B. Heavy menstrual periods
C. Hypertension
D. Hypothermia
Explanation
Choices A and D are correct. Lanugo (Choice A) is defined as “fine and soft hair that covers the body and limbs of a human fetus/ newborn.” It is abnormal for a 16-year-old to have lanugo. In a patient who is severely underweight and has lost a large amount of subcutaneous fat, such as in a patient with anorexia nervosa, the body will develop lanugo as a way to insulate itself.
Hypothermia (Choice D) is a severe complication of anorexia nervosa. Subcutaneous fat is necessary to insulate the body and regulate the temperature. Clients with anorexia nervosa lose a significant amount of subcutaneous fat due to malnourishment and weight loss. Consequently, they are prone to Hypothermia.
B is incorrect. Amenorrhea (lack of menstrual period) rather than increased menses is a complication seen in anorexia nervosa—self-inflicted starvation in anorexia nervosa results in malnourishment, hormonal imbalance, and amenorrhea.
C is incorrect. Hypotension is seen in anorexia nervosa, not hypertension. Clients with anorexia are prone to malnourishment and dehydration. Dehydration results in fluid-volume deficit and hypotension. Electrolyte imbalance such as Hypernatremia is also seen due to free water deficit and concentrated body fluids.
The condition of metabolic acidosis is indicated by which of the following arterial blood gas values?
A. Bicarbonate 15 mEq/L
B. pCO2 47 mm Hg
C. paO2 90 mm Hg
D. pH 7.34
Explanation
Choice A is correct. The bicarbonate level is well below average, which indicates metabolic acidosis. Normal bicarbonate levels are 22 to 26 mEq/L in adults.
Acid-base disorders, including metabolic acidosis, are disturbances in the balance of plasma acidity. Any process that increases the serum hydrogen ion concentration is a distinct acidosis. The term acidemia is used to define the total acid-base status of the serum pH. Acidosis classifies as either a respiratory acidosis that involves changes in carbon dioxide or metabolic acidosis, which is influenced by bicarbonate (HCO3).
Metabolic acidosis is a clinical disturbance defined by a pH of less than 7.35 and a low HCO3 level. It is characterized by an increase in the hydrogen ion concentration in the systemic circulation resulting in a serum HCO3 less than 22 mEq/L. Metabolic acidosis is not benign and signifies an underlying disorder that needs to be corrected to minimize morbidity and mortality. The many etiologies of metabolic acidosis are classified into four main mechanisms: increased acid production, decreased acid excretion, acid ingestion, and renal or gastrointestinal (GI) bicarbonate losses.
Choice B is incorrect. This value does not represent metabolic acidosis. The normal range for CO2 is 23 to 29 mEq/L. An elevated CO2 level indicates respiratory acidosis.pCO2>40 with a pH<7.4 indicates respiratory acidosis, and pCO2<40 and pH>7.4 indicates respiratory alkalosis.
Choice C is incorrect. PaO2 is between 75 and 100 mmHg (at sea level) when the body is functioning normally. A result in this range means a sufficient amount of oxygen flowing from the alveoli to the blood.
Choice D is incorrect. The pH scale ranges from 0 (strongly acidic) to 14 (strongly necessary or alkaline). A pH of 7.0, in the middle of this scale, is neutral. However, blood is usually slightly essential, with an average pH range of 7.35 to 7.45. Typically, the body maintains the pH of blood close to 7.40. therefore, any blood pH less than 7.35 is regarded as “Acidosis,” and more than 7.45 is considered alkalosis.” However, pH alone will not tell us whether we are dealing with metabolic or respiratory type imbalance. A pH of 7.34 is Acidosis, but without looking at bicarbonate and C02, you will not be able to determine whether it is metabolic or respiratory type acidosis.
The nurse is caring for a client with tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit - Ventriculat Fibrillation Rhythm
A. Initiate a code blue
B. Establish intravenous (IV) access
C. Notify the primary healthcare physician (PHCP)
D. Assess the client’s airway, breathing, and circulation
Explanation
Choice D is correct. The tracing indicated that the client is experiencing ventricular fibrillation (Vfib). This is a fatal rhythm. However, the priority action of the nurse is to immediately establish the validity of this fatal arrhythmia tracing by assessing the client’s airway, breathing, and circulation. Ventricular fibrillation is characterized by a complete lack of coordinated contraction, resulting in chaotic electrical activity on the rhythm strip. Due to rapid ventricular contractions, the ventricular filling decreases markedly, leading to a significant decrease in cardiac output. Consequently, a pulse is absent. Clinically, at the time of the event, the patient should be pulseless, unconscious, and unresponsive.
Please note that the same question may be presented differently with assessment findings disclosed within the question ( e.g.: information such as patient is unresponsive and pulse is absent within the question stem), the answer would then be Choice A. (Proceed with CPR and defibrillation because assessment has already been completed).
Choices A, B, and C are incorrect. None of these options can be implemented until the validity of the rhythm is established. The nurse should clinically validate the rhythm before proceeding to call code blue. Once the client’s vitals validate this fatal rhythm, cardiopulmonary resuscitation (CPR), according to Advanced Cardiac Life Support (ACLS) guidelines, should be initiated immediately and the physician must be notified.
The nurse is developing a plan of care for a patient who has a borderline personality disorder (BPD). Which of the following would be an expected finding? Select all that apply.
A. Self-mutilating behaviors.
B. Hypervigilance.
C. Emotional detachment.
D. Social inhibition.
E. Impulsivity.
Explanation
Correct Answers: A, E
Borderline personality disorder (BPD) is a common personality disorder that features extreme emotional lability. Impulsivity. Self-mutilative behaviors. And manipulating mannerisms. Hypervigilance is an expected finding with a paranoid personality disorder. Social inhibition is consistent with an avoidant. And emotional detachment compatible with schizoid.
The nurse is attending a client who is just diagnosed with terminal cancer. He continues to claim the "cancer is just going to disappear on its own." Knowing that this is an acceptable response by the client, please arrange the following stages of the Kübler-Ross model of grieving in the correct order:- Denial Anger Bargaining Depression Acceptance
Explanation
The correct order of sequence is Denial, Anger, Bargaining, Depression, and Acceptance ( DABDA).
Denial: Refuses to believe that loss is happening. The client is unready to deal with practical problems, such as prosthesis, after the loss of a leg. May assume artificial cheerfulness to prolong denial. This client is currently in Denial. Anger: The client or family may direct anger at nurses or staff about matters that generally would not bother them. Bargaining: Seeks to bargain to avoid loss (e.g., “let me just live until and then I will be ready to die”). Depression: Grieves over what has happened and what cannot be. May talk freely (e.g., reviewing past losses such as money or a job), or may withdraw. Acceptance: Comes to terms with the loss. May have decreased interest in surroundings and support people. May wish to begin making plans (e.g., will, prosthesis, altered living arrangements).
A 12 year old client with chronic asthma exacerbations has decided to try guided imagery as a way to manage anxiety that is contributing to frequent asthma attacks. Which statement by the client indicates an understanding of this stress reduction technique?
A. “I can do this anytime and anywhere when I feel anxious”
B. “I must be lying down to practice guided imagery”
C. “My mom will have to be with me any time I try this”
D. “I will play music every time I do my guided imagery to make sure it works.”
Explanation
Answer: A
A is correct. Guided imagery is a stress reduction technique that can be done in any place at any time. In fact, this is one of the biggest advantages of this technique. Anytime the patient begins to feel anxious, they can practice guided imagery.
B is incorrect. Guided imagery can be done in any position that the patient is comfortable in. They do not have to by lying down unless they choose to.
C is incorrect. It is not necessary for the client’s mom or anyone else to be present for guided imagery unless they choose so. Any person, or no one at all, can be present depending on the client’s preferences.
D is incorrect. Music can or can not be played during guided imagery, again depending on the client’s preferences. There does not have to be music played to make sure guided imagery works.
The doctor is explaining to a patient’s family that she is experiencing respiratory acidosis. What would Arterial Blood Gas (ABG) values suggest this to the doctor?
A. pH 7.30, CO2 38, HCO3 18
B. pH 7.48, CO2 31, HCO3 24
C. pH 7.42. CO2 36. HCO3 24
D. pH 7.3, CO2 52, HCO3 29
Explanation
Choice D is correct. This acid-base balance represents respiratory acidosis. Low pH, high CO2 represent respiratory acidosis. Although HC03- here is a bit higher than usual, it does not mean there is alkalosis because pH is 7.3 and is considered acidosis. The initial problem based on high C02 and low pH appears to be “Respiratory acidosis.” Higher Bicarbonate here is likely from renal compensation, conserving the bicarbonate to restore the pH towards normal. In this case, respiratory acidosis has been only “partially” compensated by renal conservation because it is still acidic. Examples of Respiratory Acidosis include reduced respiratory drive (Co2 retention) from opioid intoxication and COPD (chronic obstructive pulmonary disease exacerbation).
For solving an acid-base question, it is essential first to know the average values. Normal pH ranges from 7.35 to 7.45. Standard bicarbonate ranges from 22 to 26 mEQ/L. Normal pCo2 ranges from 35 to 45 mm Hg.
Choice A is incorrect. This acid-base imbalance represents metabolic acidosis because the pH level is low, and the bicarbonate level is low. Examples include increased anion gap acidosis disorders like Diabetic Ketoacidosis and lactic acidosis as well as non-gap metabolic acidosis disorders like bicarbonate loss from severe diarrhea, and renal tubular acidosis.
Choice B is incorrect. This acid-base imbalance represents respiratory alkalosis because the pH is high, and the CO2 is low. The client is ventilating/ breathing rapidly and washing out CO2. Examples of respiratory alkalosis include hyperventilation from anxiety and pulmonary embolism.
Choice C is incorrect. These values represent typical ABG values.
You are caring for a client with chronic lung disease who is being maintained with mechanical ventilation. You have just gotten this client’s laboratory results, and the client’s pH is 7.24. Which is the most appropriate nursing diagnosis for this client?
A. Metabolic alkalosis related to chronic lung disease
B. Metabolic acidosis related to chronic lung disease
C. Respiratory alkalosis related to chronic lung disease
D. Respiratory acidosis related to chronic lung disease
Explanation
Choice D is correct.The normal pH is from 7.35 to 7.45. A pH of less than 7.35 indicates the presence of acidosis, and a pH higher than 7.45 indicates the presence of alkalosis. The client’s pH of 7.24 indicates the presence of respiratory acidosis related to chronic lung disease. Patients with chronic lung diseases such as chronic obstructive pulmonary disease have problems ventilating and retain CO2 chronically. Increased pCO2 results in respiratory acidosis.
In mechanically ventilated clients, ventilator settings ( tidal volume and respiratory rate) can be adjusted to clear CO2 and correct respiratory acidosis.
Choice A is incorrect. The client’s pH of 7.24 indicates acidosis, not alkalosis. Metabolic alkalosis can occur as a result of vomiting, Cushing’s syndrome, and other causes.
Choice B is incorrect. The client’s pH of 7.24 does indicate acidosis. However, chronic lung diseases result in respiratory acidosis, not metabolic acidosis. Metabolic acidosis can occur as a result of renal disease, chronic diarrhea, cardiac arrest, and lactic acidosis.
Choice C is incorrect. The client’s pH of 7.24 indicates acidosis, not alkalosis. Respiratory alkalosis can occur as a result of hyperventilation ( Co2/ acid washed out). Hyperventilation may be seen with anxiety, salicylate toxicity, fever (hyperpyrexia), or as compensation to metabolic acidosis.
This video will provide an in-depth explanation of Arterial Blood Gas interpretation ( 19-minutes time):
https://www.youtube.com/watch?v=Qh1J8dcLpqw&feature=youtu.be
