A client begins to hyperventilate after learning that a breast ...

[madam-professor]

A client begins to hyperventilate after learning that a breast biopsy was positive for cancer. After a few minutes, the client loses consciousness. Which action by the nurse is the priority?
 
  A) Begin cardiopulmonary resuscitation.
  B) Raise the side rails on the bed.
  C) Notify the physician.
  D) Insert an intravenous access device.

Question 2

A client is brought to the emergency department with rapid breathing after learning of a family member being killed in a house fire. What should the nurse do first to help this client?
 
  A) Coach to slow the breathing.
  B) Move to a quiet, calm environment.
  C) Provide a sedative.
  D) Ask for a psychiatric consultation.

[macybarnes]

Answer to Question 1

Answer: B

The nurse should protect the client from injury. If hyperventilation continues to the point where the client loses consciousness, respirations will return to normal, as will acid-base balance. The nurse should ensure for the client's safety and raise the side rails on the bed. The client does not need cardiopulmonary resuscitation. The physician may need to be notified; however, the client's safety is a priority. The client is not critically ill and an intravenous access device is not indicated at this time.

Answer to Question 2

Answer: B

Nursing care is focused on reducing anxiety through manipulation of the environment to reduce stimuli and to create a sense of peace. This restful environment will help the client breathe more slowly and effectively. Once the environment is controlled, the nurse can begin to implement interventions to help the client slow the breathing rate. A sedative may be prescribed; however, this would not be the first intervention. A psychiatric consult might be indicated for someone with a history of anxiety or panic attacks that lead to the development of respiratory alkalosis. Since this client has had a shock, a psychiatric consultation would not be indicated at this time.

[madam-professor]

Gracias!

[cdmart10]

Excellent