A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Dyspnea

Oliguria

Pitting edema

Fatigue

Answer and Explanation

The Correct Answer is D

Hypokalemia is a low serum potassium level, usually below 3.5 mEq/L. It can be caused by diuretics that increase potassium excretion, such as thiazides or loop diuretics. Potassium is essential for normal muscle and nerve function, and hypokalemia can impair cardiac, skeletal, and smooth muscle activity. Symptoms of hypokalemia include fatigue, weakness, muscle cramps, arrhythmias, constipation, and hyporeﬂexia.

Dyspnea is difficulty or labored breathing that can be caused by various respiratory or cardiac conditions, such as asthma, pneumonia, pulmonary edema, or heart failure. It is not a specific sign of hypokalemia, although severe hypokalemia can aﬀect respiratory muscle function and cause respiratory failure.
Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. It can be caused by various renal or ﬂuid balance disorders, such as acute kidney injury, dehydration, or shock. It is not a specific sign of hypokalemia, although severe hypokalemia can impair renal function and cause renal failure.
Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. It can be caused by various ﬂuid retention disorders, such as heart failure, liver cirrhosis, or nephrotic syndrome. It is not a specific sign of hypokalemia, although severe hypokalemia can aﬀect ﬂuid and electrolyte balance and cause edema.

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Correct Answer is D

Explanation

Taking one tablet at the first indication of chest pain is the correct way to use SL nitroglycerin tablets, as they are fast- acting and can relieve anginal symptoms within minutes. The client should place the tablet under the tongue and let it dissolve.

Taking this medication after each meal and at bedtime is not appropriate, as SL nitroglycerin tablets are not meant for routine or prophylactic use, but only for acute episodes of angina.

Taking one tablet every 15 min during an acute attack is not correct, as the client should not exceed three doses in 15 min. If the pain is not relieved after three doses, the client should seek emergency medical attention.

Taking this medication with 8 ounces of water is not necessary, as SL nitroglycerin tablets do not need to be swallowed or washed down with water. They should be dissolved under the tongue for optimal absorption.

A. "Use simple, childlike statements when speaking." B. "Incorporate nonverbal cues in the conversation." C. "Use a higher-pitched tone of voice when speaking." D. "Ask multiple choice questions as part of the conversation."

Correct Answer is A

Explanation

Aphasia is a language disorder that aﬀects the ability to understand or produce speech. It can be caused by damage to the brain regions that control language, such as from a stroke. Depending on the type and severity of aphasia, the client may have difficulty with comprehension, expression, reading, or writing. Communication strategies for clients with aphasia include using nonverbal cues, such as gestures, facial expressions, pictures, or objects, to supplement verbal messages and enhance understanding.

The other options are not correct because:

a. "Use simple, childlike statements when speaking." This statement is incorrect because it is patronizing and disrespectful to the client. The client's cognitive and intellectual abilities are not aﬀected by aphasia, only their language skills. The nurse should use simple and clear sentences, but not childish or demeaning ones.

c. "Use a higher-pitched tone of voice when speaking." This statement is incorrect because it is unnecessary and may be irritating to the client. The client's hearing is not aﬀected by aphasia, only their language processing. The nurse should use a normal tone of voice and speak slowly and clearly.

d. "Ask multiple choice questions as part of the conversation." This statement is incorrect because it may be confusing and frustrating to the client. The client may have difficulty with verbal output or comprehension, and

multiple choice questions may add to their cognitive load. The nurse should ask yes or no questions or use gestures or pictures to elicit responses from the client.

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A home health nurse is making a home visit to a client who takes a daily diuretic for heart failure. Which of the following manifestations should the nurse identify as indicating the client is hypokalemic?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

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