A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?
Muscle weakness
Oliguria
Hypoactive bowel sounds
Hypertension
The Correct Answer is A
A. Muscle weakness: Hyperkalemia disrupts normal muscle cell function by affecting membrane excitability, leading to symptoms like muscle weakness or even paralysis in severe cases. It is one of the hallmark signs of elevated potassium levels.
B. Oliguria: While hyperkalemia may be associated with renal impairment, oliguria is not a direct manifestation of high potassium but rather a possible contributing factor. It is not specific to hyperkalemia itself.
C. Hypoactive bowel sounds: Increased potassium levels typically cause hyperactivity of the gastrointestinal tract, leading to hyperactive bowel sounds and cramping, not reduced or hypoactive activity.
D. Hypertension: Hyperkalemia more commonly results in hypotension due to its effects on cardiac conduction and vasculature. Hypertension is not a typical manifestation of elevated serum potassium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Flaxseed: Flaxseed is primarily used for its fiber content and potential cholesterol-lowering effects; it is not commonly associated with causing hypotension during surgery.
B. Soy: Soy contains phytoestrogens and may affect hormone levels, but it does not typically increase the risk of hypotension during surgery.
C. Probiotics: Probiotics help maintain gut flora balance and generally have no direct effect on blood pressure or hypotension risk during surgery.
D. Black cohosh: Black cohosh has vasodilatory properties and can lower blood pressure, increasing the risk of hypotension during surgery, especially when combined with anesthesia or other medications.
Correct Answer is C
Explanation
A. Keep a monthly calendar in the client's kitchen: A calendar showing a full month may be difficult for a client with Alzheimer's disease to process due to impaired memory and orientation. Simpler visual aids or daily reminders are more effective in supporting cognitive function.
B. Provide distraction by keeping the television on: Leaving the television on continuously can overstimulate the client and contribute to confusion or agitation. Clients with Alzheimer's often benefit more from calm, structured environments than from constant auditory input.
C. Install a nightlight in the client's bedroom: Installing a nightlight helps maintain orientation and reduce nighttime confusion. It also lowers the risk of falls by making it easier for the client to navigate their environment if they wake during the night.
D. Place a deadbolt lock on the client's bedroom door: Locking the client in their bedroom poses serious safety concerns, especially in emergencies like a fire. It may also increase anxiety or fear. Safer wandering prevention measures include door alarms or monitoring systems.
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