A nurse is caring for a patient whose sodium level is 118 mEq/L. Which nursing diagnosis is a priority for this patient?

Comfort, Impaired

Disturbed Sensory Perception

Deficient Fluid Volume

Risk for Injury

Answer and Explanation

The Correct Answer is B

Choice A: Comfort, Impaired is not a priority nursing diagnosis for this patient, because this condition is not directly related to the low sodium level. Comfort, Impaired is a state of physical or psychological discomfort that can aﬀect the patient's well-being and quality of life.

Choice B: Disturbed Sensory Perception is a priority nursing diagnosis for this patient, because this condition is a serious complication of the low sodium level. Disturbed Sensory Perception is a state of altered or impaired perception of reality that can aﬀect the patient's cognitive and neurological functions. Low sodium level can cause cerebral edema, which is a swelling of the brain that can lead to confusion, seizures, coma, and death.

Choice C: Deficient Fluid Volume is not a priority nursing diagnosis for this patient, because this condition is not the cause of the low sodium level. Deficient Fluid Volume is a state of decreased intravascular, interstitial, or intracellular ﬂuid that can aﬀect the patient's ﬂuid and electrolyte balance. Low sodium level can be caused by excess ﬂuid intake, ﬂuid retention, or loss of sodium from the body.

Choice D: Risk for Injury is not a priority nursing diagnosis for this patient, because this condition is not specific to the low sodium level. Risk for Injury is a state of vulnerability to physical or psychological harm that can aﬀect the patient's safety and health. Low sodium level can increase the risk of injury from falls, accidents, or seizures.

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Correct Answer is B

Explanation

Choice A: Hyperkalemia is not an imbalance that this patient is demonstrating, because this condition occurs when the blood potassium level is too high. This can happen in patients who have renal failure, acidosis, or excessive potassium intake. Hyperkalemia can cause muscle weakness, cardiac arrhythmias, and paralysis.

Choice B: Hyponatremia is an imbalance that this patient is demonstrating, because this condition occurs when the blood sodium level is too low. This can happen in patients who have watery diarrhea, which causes the loss of sodium and water from the body. Hyponatremia can cause abdominal and muscle cramping, nausea, confusion, and seizures.

Choice C: Fluid volume excess is not an imbalance that this patient is demonstrating, because this condition occurs when the body retains more ﬂuid than it excretes. This can happen in patients who have heart failure, kidney failure, or excessive ﬂuid intake. Fluid volume excess can cause edema, distended neck veins, and crackles in the lungs.

Choice D: Hypernatremia is not an imbalance that this patient is demonstrating, because this condition occurs when the blood sodium level is too high. This can happen in patients who have dehydration, diabetes insipidus, or excessive sodium intake. Hypernatremia can cause thirst, dry mucous membranes, agitation, and coma.

A. Patient with venous stasis ulcer B. Patient on dialysis C. Patient with bulimia D. Patient with COPD

Correct Answer is C

Explanation

Choice A: A patient with venous stasis ulcer is not at increased risk for metabolic alkalosis, because this condition does not aﬀect the acid-base balance of the body. Venous stasis ulcer is a chronic wound that occurs due to impaired blood ﬂow in the lower extremities.

Choice B: A patient on dialysis is not at increased risk for metabolic alkalosis, because dialysis helps to remove excess acids and bases from the blood. Dialysis is a treatment that filters and purifies the blood using a machine.

Choice C: A patient with bulimia is at increased risk for metabolic alkalosis, because this condition involves frequent vomiting that causes loss of gastric acid. Gastric acid is a source of hydrogen ions that lowers the pH of the blood. When gastric acid is lost, the blood becomes more alkaline.

Choice D: A patient with COPD is not at increased risk for metabolic alkalosis, but rather for respiratory acidosis. This is because COPD impairs the ability of the lungs to eliminate carbon dioxide, which is a source of carbonic acid that lowers the pH of the blood. When carbon dioxide accumulates, the blood becomes more acidic.

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A nurse is caring for a patient whose sodium level is 118 mEq/L. Which nursing diagnosis is a priority for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older patient comes into the clinic complaining of watery diarrhea for several days with abdominal and muscle cramping. The nurse realizes that this patient is demonstrating which imbalance?

Correct Answer is B

Explanation

The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?

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A nurse is caring for a client who is receiving IV ﬂuids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is eﬀectively responding to treatment?

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The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most aﬀected by this disorder?

A patient with chronic renal failure has an occluded arteriovenous fistula, and routine hemodialysis is delayed. However, the patient's serum potassium level is 6.0 mEq/L. What should the nurse expect to be prescribed for this patient? (Select all that apply.)

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