A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?
Hyporeflexia.
Constipation.
Increased appetite.
Headache.
The Correct Answer is D
The correct answer is Choice D: Headache.
Rationale for Choice D (Headache): Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to various neurological symptoms due to the altered osmotic pressure in the brain cells. When the sodium level drops below normal, water moves into the cells, causing them to swell, which can lead to increased intracranial pressure and subsequent headaches. Therefore, a client with a sodium level of 128 mEq/L is likely to experience headaches as a manifestation of hyponatremia.
Rationale for other choices:
Choice A: Hyporeflexia Hyporeflexia refers to diminished or absent reflexes. While hyponatremia can affect neurological function, hyporeflexia is not a typical manifestation. Instead, hyperreflexia may occur in severe cases due to cerebral edema and increased intracranial pressure.
Choice B: Constipation Constipation is not a common manifestation of hyponatremia. Gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping may occur, but constipation is not typically associated with sodium imbalances.
Choice C: Increased appetite Hyponatremia does not typically cause increased appetite. Instead, gastrointestinal symptoms such as nausea and anorexia are more commonly observed. Increased appetite is not directly related to sodium levels but may be seen in conditions such as hyperthyroidism or certain medications.
Therefore, based on the provided data and typical manifestations of hyponatremia, the correct answer is Choice D: Headache. This is because headaches are a common neurological symptom associated with low sodium levels and increased intracranial pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Taking hydrochlorothiazide on an empty stomach is not a requirement for this medication. Hydrochlorothiazide is a diuretic used to treat conditions like hypertension and edema. It can be taken with or without food, and food may help reduce stomach upset for some individuals.
Choice B rationale:
Muscle weakness is an adverse effect of hydrochlorothiazide. Therefore, it is not an expected outcome. Hydrochlorothiazide is a thiazide diuretic, and one of its common side effects is potassium loss through increased urine output. This can lead to muscle weakness and cramping. The nurse should educate the client about the signs and symptoms of low potassium and the importance of including potassium-rich foods in their diet.
Choice C rationale:
Increasing daily intake of foods high in potassium is essential information to include in the teaching for a client taking hydrochlorothiazide. Thiazide diuretics like hydrochlorothiazide can cause potassium depletion, which may result in adverse effects like muscle weakness, cramping, and cardiac dysrhythmias. Therefore, advising the client to consume potassium-rich foods, such as bananas, oranges, and potatoes, can help counteract the potassium loss associated with the medication.
Choice D rationale:
Taking the medication at bedtime is not a specific requirement for hydrochlorothiazide. Thiazide diuretics can be taken at various times of the day, depending on the client's preferences and when they are most compliant with their medication regimen. The timing of administration should be consistent to maintain the medication's effectiveness.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should instruct the client to consume foods rich in potassium because furosemide, a loop diuretic, can lead to potassium depletion. By consuming potassium-rich foods, the client can help maintain proper electrolyte balance. Common potassium-rich foods include bananas, oranges, potatoes, and leafy greens. It is crucial to prevent hypokalemia, as it can result in adverse effects such as cardiac dysrhythmias and muscle weakness.
Choice B rationale:
Taking furosemide at bedtime is not necessary, and it is not a standard instruction. Furosemide is usually taken in the morning to avoid nocturia, as it increases urine output. This option does not address the primary concern of managing pulmonary edema and the potential electrolyte imbalances associated with furosemide use.
Choice C rationale:
Taking aspirin for headaches is not relevant to the client's condition of pulmonary edema or the use of furosemide. This choice does not provide valuable guidance to the client and may lead to unnecessary medication use.
Choice D rationale:
Expecting swelling in the hands and feet is not an appropriate instruction for a client with pulmonary edema. The goal of furosemide therapy is to reduce edema and fluid retention, not to expect or tolerate swelling. This option does not contribute to the client's well-being and recovery.
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