A nurse is caring for a client.

Exhibits

The nurse is collecting data from the client 12 hr later.

How should the nurse interpret the following findings?

For each potential finding, click to specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

Vision

Lithium level

Urine output

Mucous membranes

Vital signs

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Vision (Blurred)
- Interpretation: Potential worsening condition
- Rationale: Blurred vision can be a sign of lithium toxicity. Despite the lithium level improving, this symptom indicates that neurotoxicity may still be present.
Lithium Level (1.2 mEq/L)
- Interpretation: Potential improvement
- Rationale: The lithium level has decreased from 1.8 mEq/L (toxic) to 1.2 mEq/L, which is within the therapeutic range (0.6-1.2 mEq/L). This indicates that treatment to lower lithium toxicity is effective.
Urine Output (40 mL/hr)
- Interpretation: Potential improvement
- Rationale: A urine output of 40 mL/hr is within the acceptable range (normal is greater than 30 mL/hr), suggesting that kidney function is adequate and not compromised by lithium toxicity.
Mucous Membranes (Pale, Dry)
- Interpretation: Potential worsening condition
- Rationale: Pale, dry mucous membranes suggest dehydration, which can increase the risk of lithium toxicity and negatively affect overall health.
Vital Signs (BP 88/50 mm Hg, Pulse 96/min)
- Interpretation: Potential worsening condition
- Rationale: The drop in blood pressure from 130/84 mm Hg to 88/50 mm Hg indicates hypotension. This could be related to dehydration or lithium toxicity, and it requires follow-up as the condition is deteriorating.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Choice Arationale:
Holding the right arm straight is not a specific test for carpal tunnel syndrome.

Choice Brationale:
Extending the right arm upward is not a recognized test for carpal tunnel syndrome.
Choice C rationale:
Holding the wrist at a 90-degree flexion is similar to Phalen’s test, a recognized diagnostic test for carpal tunnel syndrome.
Choice D rationale:
Flexing the right arm at the elbow is not a recognized test for carpal tunnel syndrome.

A. Hypokalemia. B. Hypomagnesemia. C. Hypermagnesemia. D. Hyperkalemia.

Correct Answer is A

Explanation

The correct answer is: A

Choice A Reason: Hypokalemia refers to a lower-than-normal level of potassium in the bloodstream. Normal potassium levels are typically between 3.5 and 5.0 mEq/L. In the context of nephrotic syndrome and high-dose corticosteroid therapy, hypokalemia can occur due to increased urinary potassium losses caused by corticosteroid-induced alterations in kidney function. Corticosteroids can promote the excretion of potassium, leading to a deficiency.

Choice B Reason: Hypomagnesemia is a condition where there is a magnesium deficiency in the blood, with normal levels usually ranging between 1.7 and 2.2 mg/dL. While it can occur in nephrotic syndrome due to urinary losses of proteins that bind magnesium, it is not typically associated with corticosteroid therapy. Therefore, it is less likely to be monitored in this specific scenario.

Choice C Reason: Hypermagnesemia indicates an abnormally high level of magnesium in the blood. This condition is relatively rare and is not commonly associated with nephrotic syndrome or corticosteroid therapy. It is more often related to renal failure or excessive intake of magnesium-containing medications or supplements.

Choice D Reason: Hyperkalemia is characterized by an elevated level of potassium in the blood, with normal levels being 3.5 to 5.0 mEq/L. While hyperkalemia can occur in nephrotic syndrome due to the loss of albumin in the urine, which can affect calcium and potassium binding, corticosteroid therapy typically causes a decrease in potassium levels, making hypokalemia a more relevant concern in this context.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?

Correct Answer is A

Explanation

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