Question

A nurse is monitoring a client who has metabolic acidosis due to salicylate overdose. For which of the following findings should the nurse monitor?

-Flushed, dry skin
-Seizures
-Hyperreflexia
-Positive Trousseau's sign

Answer 1

A nurse monitoring a client with metabolic acidosis due to salicylate overdose should be vigilant for seizures, hyperreflexia, and symptoms like confusion and nausea which indicate systemic toxicity and central nervous system involvement.

Step-by-step explanation:

In the case of a client with metabolic acidosis due to salicylate overdose, a nurse should monitor for various clinical manifestations associated with toxicity. Important findings to monitor include:

• Seizures: Salicylates affect the central nervous system and can lead to seizures, especially with high doses or chronic use.
• Possible hyperreflexia: Excess acid can lead to increased excitability of neuronal membranes, which may present as increased reflexes.
• Confusion and nausea: Metabolic acidosis can cause a disturbance in mental status as well as gastrointestinal upset.

Other less common findings could include changes in skin color and other signs typically associated with severe salicylate poisoning or systemic toxicity.