A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)

Restrict fluid intake

Monitor neurological status

Administer hypotonic IV fluids

Encourage foods high in sodium

Provide oral hygiene frequently

Answer and Explanation

Correct Answer : B,C,E

Choice A reason:

Restricting fluid intake is not an action that the nurse should take for a client who has hypernatremia. Fluid restriction can worsen hypernatremia by increasing the concentration of sodium in the blood. Fluid intake should be increased or replaced with isotonic or hypotonic fluids to dilute sodium and correct hypernatremia.

Choice B reason:

Monitoring neurological status is an action that the nurse should take for a client who has hypernatremia. Hypernatremia can cause neurological symptoms such as confusion, agitation, seizures, coma, and death due to cellular dehydration and brain shrinkage. The nurse should assess the client's level of consciousness, orientation, memory, behavior, and reflexes regularly and report any changes or deterioration.

Choice C reason:

Administering hypotonic IV fluids is an action that the nurse should take for a client who has hypernatremia. Hypotonic fluids have a lower concentration of solutes than normal body fluids and can help lower serum sodium levels by moving water into the cells from the blood vessels. The nurse should administer hypotonic fluids slowly and carefully to avoid fluid overload or cerebral edema.

Choice D reason:

Encouraging foods high in sodium is not an action that the nurse should take for a client who has hypernat

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Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Applying a moist dressing to the wound provides a moist environment for wound healing and protects the wound from contamination and trauma. Moisture prevents dehydration and necrosis of the wound bed and promotes cell migration and growth.

Choice B reason:

Assessing the wound for signs of infection is important to detect and treat any infection that may impair wound healing or cause systemic complications. Signs of infection include increased redness, warmth, swelling, pain, drainage, odor, fever, or leukocytosis.

Choice C reason:

Debriding necrotic tissue from the wound is essential to remove any dead or devitalized tissue that may interfere with wound healing or serve as a source of infection. Debridement can be done by surgical, mechanical, enzymatic, or autolytic methods.

Choice D reason:

Elevating the affected leg above the heart level reduces edema and improves blood circulation to the wound. Edema can impair wound healing by causing tissue hypoxia, increasing bacterial growth, and delaying granulation tissue formation.

Choice E reason:

Massaging the wound edges gently is not recommended for chronic wounds, as it may cause trauma or bleeding to the wound bed or delay epithelialization. Massaging may be beneficial for preventing hypertrophic scars or contractures in healed wounds.

A. B cells B. T cells C. T cells D. Mast cells

Correct Answer is B

Explanation

Choice A reason:

B cells are not involved in contact dermatitis, as they do not produce antibodies or form immune complexes.

Choice B reason:

T cells are the type of cells that mediate contact dermatitis, which is a type of type IV hypersensitivity. T cells recognize the poison ivy antigens that bind to the skin proteins and release cytokines that recruit macrophages and other inflammatory cells. This leads to a delayed and localized reaction that manifests as erythema, edema, vesicles, and pruritus.

Choice C reason:

T cells are not the same as B cells, as they have different receptors and functions in the immune system.

Choice D reason:

Mast cells are not involved in contact dermatitis, as they do not express IgE antibodies or release histamine.

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A nurse is caring for a client who has hypernatremia. Which of the following actions should the nurse take? (Select all that apply.)

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Explanation

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