A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following:
- pH is 7.12 (normal range: 7.35-7.45)
- PaCO2 is 90 mm Hg (normal range: 35-45)
- HCO3- is 22 mEq/L (normal range: 22-26)
The nurse interprets the results as indicating which condition?
Metabolic alkalosis
Respiratory alkalosis
Respiratory acidosis
Metabolic acidosis
The Correct Answer is C
A. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.
B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.
C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.
D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.
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Correct Answer is D
Explanation
A. Checking pupillary response to light assesses cranial nerve II (optic nerve).
B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).
C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).
D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.
Correct Answer is D
Explanation
A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.
B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.
C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.
D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.