Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has chronic respiratory acidosis due to chronic obstructive pulmonary disease (COPD). Which of the following findings should the nurse expect with this client?
A. Osteoporosis
Osteoporosis is inappropriate. Chronic respiratory acidosis can lead to osteoporosis over time due to several factors, including chronic hypoxemia, which can affect bone metabolism and lead to bone loss.
B. Polyuria
Polyuria is inappropriate. Polyuria, or increased urination, is not typically associated with chronic respiratory acidosis. In fact, respiratory acidosis tends to cause retention of bicarbonate ions, which can lead to compensatory metabolic alkalosis and decreased urine output.
C. Anxiety and depression
Anxiety and depression is inappropriate. Chronic respiratory acidosis can lead to symptoms such as lethargy, confusion, and decreased mental acuity due to the effects of elevated CO2 levels on the central nervous system. While anxiety and depression are not direct consequences of chronic respiratory acidosis, individuals with COPD may experience anxiety and depression as a result of their chronic respiratory condition.
D. Delirium
Delirium is correct. Delirium, characterized by an acute change in mental status, confusion, and altered consciousness, can occur in severe cases of chronic respiratory acidosis, especially during acute exacerbations. Elevated CO2 levels can affect brain function and lead to symptoms of delirium.
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Full Explanation
Choice A Reason:
Osteoporosis is inappropriate. Chronic respiratory acidosis can lead to osteoporosis over time due to several factors, including chronic hypoxemia, which can affect bone metabolism and lead to bone loss.
Choice B Reason:
Polyuria is inappropriate. Polyuria, or increased urination, is not typically associated with chronic respiratory acidosis. In fact, respiratory acidosis tends to cause retention of bicarbonate ions, which can lead to compensatory metabolic alkalosis and decreased urine output.
Choice C Reason:
Anxiety and depression is inappropriate. Chronic respiratory acidosis can lead to symptoms such as lethargy, confusion, and decreased mental acuity due to the effects of elevated CO2 levels on the central nervous system. While anxiety and depression are not direct consequences of chronic respiratory acidosis, individuals with COPD may experience anxiety and depression as a result of their chronic respiratory condition.
Choice D Reason:
Delirium is correct. Delirium, characterized by an acute change in mental status, confusion, and altered consciousness, can occur in severe cases of chronic respiratory acidosis, especially during acute exacerbations. Elevated CO2 levels can affect brain function and lead to symptoms of delirium.
Similar Questions
A client who has a history of migraines reports to a clinic with a throbbing headache. Which of the following questions should the nurse include in the assessment?
(Select All that Apply.)
A. "Have you had any nausea and vomiting with your headache?"
"Have you had any nausea and vomiting with your headache?": This question is appropriate. Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm the diagnosis of a migraine headache.
B. "Are you bothered by the lights in here?"
"Are you bothered by the lights in here?" This question is appropriate. Sensitivity to light, known as photophobia, is a classic symptom of migraines. Inquiring about light sensitivity can provide additional evidence for the diagnosis.
C. "Have you noticed any confused or cloudy thinking?"
"Have you noticed any confused or cloudy thinking?". This question is inappropriate. Confusion or cognitive symptoms are not typical of migraines. However, some individuals may experience difficulty concentrating or cognitive symptoms during a migraine aura. This question may help assess for aura symptoms.
D. "Have you experienced or are you experiencing any strange smells?"
Have you experienced or are you experiencing any strange smells?" This question is appropriate. Some individuals may experience olfactory hallucinations or sensitivity to odors during a migraine aura. Asking about strange smells can help identify possible aura symptoms.
E. "Did you feel weak before the headache started or do you feel weak now?"
"Did you feel weak before the headache started or do you feel weak now?" This question is inappropriate. While weakness is not a typical symptom of migraines, some individuals may experience fatigue or muscle weakness during a migraine attack. This question may help assess the overall impact of the headache on the client.
Full Explanation
Choice A Reason:
"Have you had any nausea and vomiting with your headache?": This question is appropriate. Nausea and vomiting are common symptoms associated with migraines. Asking about these symptoms can help confirm the diagnosis of a migraine headache.
Choice B Reason:
"Are you bothered by the lights in here?" This question is appropriate. Sensitivity to light, known as photophobia, is a classic symptom of migraines. Inquiring about light sensitivity can provide additional evidence for the diagnosis.
Choice C Reason:
"Have you noticed any confused or cloudy thinking?". This question is inappropriate. Confusion or cognitive symptoms are not typical of migraines. However, some individuals may experience difficulty concentrating or cognitive symptoms during a migraine aura. This question may help assess for aura symptoms.
Choice D Reason
Have you experienced or are you experiencing any strange smells?" This question is appropriate. Some individuals may experience olfactory hallucinations or sensitivity to odors during a migraine aura. Asking about strange smells can help identify possible aura symptoms.
Choice E Reason:
"Did you feel weak before the headache started or do you feel weak now?" This question is inappropriate. While weakness is not a typical symptom of migraines, some individuals may experience fatigue or muscle weakness during a migraine attack. This question may help assess the overall impact of the headache on the client.
A nurse is providing care to a client who has Parkinson's disease and is having difficulty swallowing. Which of the following departments should the nurse plan to contact for a consultation?
A. Nutritional therapy
Nutritional therapy is not appropriate. While nutritional therapy may be involved in assessing the client's overall nutritional status and dietary needs, it may not specifically address the swallowing difficulty associated with Parkinson's disease.
B. Speech therapy
Speech therapy is appropriate. Speech therapy, also known as speech-language pathology, plays a crucial role in assessing and managing dysphagia. Speech therapists can evaluate the client's swallowing function and provide interventions to improve swallowing safety and efficiency. Choice C Reason: Occupational therapy is incorrect. Occupational therapy focuses on helping individuals engage in meaningful activities of daily living. While occupational therapists may play a role in dysphagia management, speech therapy is typically the primary discipline involved in addressing swallowing difficulties.
C. Occupational therapy
D. Respiratory therapy
Respiratory therapy: Respiratory therapy primarily focuses on evaluating and managing respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), and ventilator support. While dysphagia can sometimes lead to aspiration pneumonia and respiratory complications, respiratory therapists are not typically involved in the assessment and management of dysphagia itself.
Full Explanation
Choice A Reason:
Nutritional therapy is not appropriate. While nutritional therapy may be involved in assessing the client's overall nutritional status and dietary needs, it may not specifically address the swallowing difficulty associated with Parkinson's disease.
Choice B Reason:
Speech therapy is appropriate. Speech therapy, also known as speech-language pathology, plays a crucial role in assessing and managing dysphagia. Speech therapists can evaluate the client's swallowing function and provide interventions to improve swallowing safety and efficiency.
Choice C Reason:
Occupational therapy is incorrect. Occupational therapy focuses on helping individuals engage in meaningful activities of daily living. While occupational therapists may play a role in dysphagia management, speech therapy is typically the primary discipline involved in addressing swallowing difficulties.
Choice D Reason:
Respiratory therapy: Respiratory therapy primarily focuses on evaluating and managing respiratory conditions, such as asthma, chronic obstructive pulmonary disease (COPD), and ventilator support. While dysphagia can sometimes lead to aspiration pneumonia and respiratory complications, respiratory therapists are not typically involved in the assessment and management of dysphagia itself.
Which of the following obstructive sleep apnea risk factors and behavioral therapies should the nurse discuss with the client?
(Select All that Apply.)
A. Sedatives does not impact the risk of obstructive sleep apnea.
Sedatives do not impact the risk of obstructive sleep apnea: This statement is incorrect. Sedatives, particularly those that cause muscle relaxation or depress the central nervous system, can exacerbate obstructive sleep apnea by further relaxing the muscles of the upper airway, leading to increased airway collapse during sleep.
B. CPAP compliance enhances quality of sleep.
CPAP compliance enhances quality of sleep is correct. Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. Compliance with CPAP therapy, meaning consistent and proper use of the CPAP device during sleep, is essential for effectively managing sleep apnea and improving sleep quality.
C. Alcohol does not affect the risk of obstructive sleep apnea.
Alcohol does not affect the risk of obstructive sleep apnea. This statement is incorrect. Alcohol consumption can worsen obstructive sleep apnea by promoting muscle relaxation in the upper airway, leading to increased airway collapse and more frequent episodes of apnea during sleep.
D. Obesity increases the risk of obstructive sleep apnea.
Obesity increases the risk of obstructive sleep apnea. This statement is correct. Obesity is a significant risk factor for obstructive sleep apnea. Excess fat tissue around the neck can increase the likelihood of airway obstruction during sleep, contributing to the development or worsening of sleep apnea.
E. Positional therapy enhances client comfort.
Positional therapy enhances client comfort is correct. Positional therapy involves strategies to encourage sleeping in positions that minimize the severity of obstructive sleep apnea, particularly for individuals with positional OSA (where apnea events are primarily or significantly worse when sleeping in specific positions, such as supine). This statement is correct.
F. Smoking increases the risk of obstructive sleep apnea.
This statement is correct. Smoking can increase the risk of obstructive sleep apnea due to its effects on upper airway inflammation and respiratory function. Smoking cessation can be beneficial in managing sleep apnea and improving overall health.
Full Explanation
Choice A Reason:
Sedatives do not impact the risk of obstructive sleep apnea: This statement is incorrect. Sedatives, particularly those that cause muscle relaxation or depress the central nervous system, can exacerbate obstructive sleep apnea by further relaxing the muscles of the upper airway, leading to increased airway collapse during sleep.
Choice B Reason:
CPAP compliance enhances quality of sleep is correct. Continuous positive airway pressure (CPAP) therapy is a common treatment for obstructive sleep apnea. Compliance with CPAP therapy, meaning consistent and proper use of the CPAP device during sleep, is essential for effectively managing sleep apnea and improving sleep quality.
Choice C Reason:
Alcohol does not affect the risk of obstructive sleep apnea. This statement is incorrect. Alcohol consumption can worsen obstructive sleep apnea by promoting muscle relaxation in the upper airway, leading to increased airway collapse and more frequent episodes of apnea during sleep.
Choice D Reason:
Obesity increases the risk of obstructive sleep apnea. This statement is correct. Obesity is a significant risk factor for obstructive sleep apnea. Excess fat tissue around the neck can increase the likelihood of airway obstruction during sleep, contributing to the development or worsening of sleep apnea.
Choice E Reason:
Positional therapy enhances client comfort is correct. Positional therapy involves strategies to encourage sleeping in positions that minimize the severity of obstructive sleep apnea, particularly for individuals with positional OSA (where apnea events are primarily or significantly worse when sleeping in specific positions, such as supine). This statement is correct.
Choice F Reason:
Smoking increases the risk of obstructive sleep apnea: This statement is correct. Smoking can increase the risk of obstructive sleep apnea due to its effects on upper airway inflammation and respiratory function. Smoking cessation can be beneficial in managing sleep apnea and improving overall health.