A nurse is caring for a client who has heart failure (HF). Which of the following should the nurse identify as a cause for the client's decreased serum osmolality?

A decrease in intracellular fluid volume

An increase in hydrostatic pressure

An increase in serum sodium

An increase in vascular fluid volume

Answer and Explanation

The Correct Answer is D

A. A decrease in intracellular fluid volume: A reduction in intracellular fluid volume often results from hypertonic conditions in the extracellular space, which can draw water out of cells. This shift can actually increase serum osmolality rather than decrease it.
B. An increase in hydrostatic pressure: Increased hydrostatic pressure promotes fluid movement from the vascular space into the interstitial tissues, contributing to edema. However, this does not significantly impact the concentration of solutes in the serum and therefore does not directly cause a decrease in osmolality.
C. An increase in serum sodium: Sodium is the main contributor to serum osmolality, so an increase in serum sodium raises osmolality. This is the opposite of what occurs in heart failure, where sodium levels are often diluted due to fluid retention.
D. An increase in vascular fluid volume: In heart failure, the kidneys retain fluid in response to decreased cardiac output, expanding the vascular volume. This excess water dilutes the concentration of solutes in the blood, such as sodium, leading to a decrease in serum osmolality.

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Correct Answer is ["A","C","E"]

Explanation

A. Swelling of the optic nerve: Swelling of the optic nerve, also known as papilledema, is a clear sign of increased intracranial pressure and indicates a worsening neurological condition. It results from pressure transmitted through the cerebrospinal fluid, leading to compromised optic nerve function.
B. Respiratory rate of 12/min: A respiratory rate of 12 breaths per minute is within normal limits for adults and does not indicate deterioration. While respiratory changes can be a late sign of increased ICP, a rate of 12 alone is not concerning.
C. Changes to pupil size and shape: Alterations in pupil size and shape often reflect pressure on cranial nerves, particularly the oculomotor nerve (CN III), which is a critical warning sign of brain herniation or increased ICP. This is a significant cue of neurologic decline.
D. Blood pressure of 108/74 mm Hg: This blood pressure reading is within a normal range and does not independently suggest a worsening neurologic condition. Worrisome signs would include widened pulse pressure or elevated systolic pressure, which may signal Cushing’s triad.
E. Decreasing Glasgow Coma scores: A drop in the Glasgow Coma Scale score indicates a decline in consciousness, which is a key sign of worsening intracranial pathology. Monitoring GCS trends is essential in patients with increased ICP to identify neurological deterioration early.

A. The client should maintain systolic BP between 141 and 145 mm Hg. B. The client should maintain systolic BP between 136 and 140 mm Hg C. The client should maintain systolic BP between 120 and 129 mm Hg. D. The client should maintain systolic BP between 130 and 135 mm Hg

Correct Answer is C

Explanation

A. The client should maintain systolic BP between 141 and 145 mm Hg. This BP range is too high for clients with hypertension, especially those who have had a transient ischemic attack (TIA). The goal is to reduce BP to lower levels to prevent further stroke risk.
B. The client should maintain systolic BP between 136 and 140 mm Hg: This is still too high. Current guidelines recommend keeping systolic BP lower to reduce the risk of recurrent strokes or further vascular damage.
C. The client should maintain systolic BP between 120 and 129 mm Hg: This is the most appropriate target for clients with hypertension and TIA. Maintaining a BP within this range is known to reduce the risk of future strokes.
D. The client should maintain systolic BP between 130 and 135 mm Hg: While this range is lower than some others, it is still above the ideal target for stroke prevention, which is under 130 mm Hg for clients at high risk.

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A nurse is caring for a client who has heart failure (HF). Which of the following should the nurse identify as a cause for the client's decreased serum osmolality?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure and has a worsening neurologic condition. Which of the following cues should the nurse recognize as a worsening condition? (Select All that Apply.)

Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is C

Explanation

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