A nurse is assessing a client who has received treatment for hypernatremia. Which of the following findings indicates the treatment has been effective?
Firm grip bilaterally
Fatigue
2+ deep tendon reflexes
Urine output 25 mL/hr
The Correct Answer is C
Choice A reason: A firm bilateral hand grip indicates normal muscle strength, which is a positive sign but not directly related to hypernatremia treatment efficacy.
Choice B reason: Fatigue is not a sign of effective treatment for hypernatremia. Fatigue can be a symptom of hypernatremia, as well as dehydration, infection, or other conditions. The nurse should assess the client for other causes of fatigue and monitor their vital signs and fluid status.
Choice C reason: Deep tendon reflexes graded as 2+ are considered normal and suggest that neuromuscular function is intact. Since hypernatremia can cause neuromuscular excitability, normal reflexes may indicate effective treatment.
Choice D reason: Urine output 25 mL/hr is not a sign of effective treatment for hypernatremia. Urine output 25 mL/hr is below the normal range of 30 to 50 mL/hr and indicates oliguria, which can be a complication of hypernatremia. Oliguria can result from dehydration, kidney damage, or reduced blood flow to the kidneys due to hypernatremia. The nurse should notify the provider and administer fluids as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Changing the feeding to a continuous infusion may not improve the constipation, as it does not address the fluid deficit or the fiber content of the formula. Continuous infusion may also increase the risk of aspiration, diarrhea, and bacterial contamination.
Choice B reason: Increasing the amount of free water can help prevent or treat constipation by hydrating the stool and facilitating its passage. The client's fluid intake and output indicate a fluid deficit, which can contribute to constipation. The recommended fluid intake for adults is 30 to 35 mL/kg/day.
Choice C reason: Decreasing the infusion rate of feeding may worsen the constipation, as it reduces the caloric and fluid intake of the client. The infusion rate should be based on the client's nutritional needs and tolerance.
Choice D reason: Requesting a prescription for a diuretic is not appropriate, as it would further dehydrate the client and aggravate the constipation. Diuretics are indicated for clients with fluid overload, not fluid deficit.
Correct Answer is B
Explanation
Choice A reason: Increased glucose levels are not a positive outcome of the client's interventions, but rather a sign of impaired glucose metabolism and insulin resistance, which can increase the risk of cardiovascular disease. The Mediterranean diet can help lower glucose levels by providing complex carbohydrates, fiber, and healthy fats, which can improve insulin sensitivity and blood sugar control.
Choice B reason: Increased HDL levels are a positive outcome of the client's interventions, as HDL stands for high-density lipoprotein, which is the "good" cholesterol that helps remove excess cholesterol from the arteries and protect against atherosclerosis and cardiovascular disease. The Mediterranean diet can help increase HDL levels by providing monounsaturated and polyunsaturated fats, such as olive oil, nuts, seeds, and fish, which can boost HDL production and function.
Choice C reason: Increased LDL levels are not a positive outcome of the client's interventions, but rather a sign of increased cholesterol deposition and inflammation in the arteries, which can lead to plaque formation and cardiovascular disease. LDL stands for low-density lipoprotein, which is the "bad" cholesterol that carries cholesterol from the liver to the cells. The Mediterranean diet can help lower LDL levels by providing antioxidants, fiber, and plant sterols, which can reduce LDL synthesis and oxidation.
Choice D reason: Increased triglyceride levels are not a positive outcome of the client's interventions, but rather a sign of increased fat storage and metabolic syndrome, which can increase the risk of cardiovascular disease. Triglycerides are a type of fat that circulates in the blood and provides energy to the cells. The Mediterranean diet can help lower triglyceride levels by providing omega-3 fatty acids, which can modulate triglyceride synthesis and breakdown.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
