A nurse is collecting data from a client who has a sodium level of 155 mEq/L. Which of the following manifestations should the nurse expect?
Cool, clammy skin.
Increased salivation.
Hypertension.
Decreased level of consciousness.
The Correct Answer is D
Choice A rationale:
Cool, clammy skin is not a typical manifestation of hypernatremia (high sodium levels). Hypernatremia is characterized by an excess of sodium in the blood, which typically leads to symptoms such as thirst, dry mucous membranes, and decreased skin turgor. Cool, clammy skin is more often associated with conditions like shock or hypoglycemia.
Choice B rationale:
Increased salivation is not a common manifestation of hypernatremia. Instead, hypernatremia often leads to signs of dehydration, including dry mouth and decreased salivation.
Choice C rationale:
Hypertension is not a direct manifestation of hypernatremia. Hypernatremia can cause increased blood pressure, but it is not one of the typical clinical signs of hypernatremia. Hypertension is more commonly associated with conditions like high sodium intake, kidney disease, or primary hypertension.
Choice D rationale:
A decreased level of consciousness is a significant manifestation of hypernatremia. Elevated sodium levels in the blood can lead to cellular dehydration, affecting brain cells and resulting in neurological symptoms such as confusion, lethargy, and decreased consciousness. Severe hypernatremia can even lead to seizures and coma. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Bananas are a good source of potassium, and the client's serum potassium level is low (3.1 mEq/L). Including potassium-rich foods like bananas in the diet can help raise the potassium level and prevent hypokalemia, which is a potential side effect of furosemide (a diuretic).
Choice B rationale:
Cheddar cheese is not a suitable choice for a client with low potassium levels. It is not a significant source of potassium and should not be the primary recommendation for addressing hypokalemia.
Choice C rationale:
Cabbage is not a good choice for increasing potassium intake. While it has some potassium, other fruits and vegetables like bananas are much richer sources of this essential electrolyte.
Choice D rationale:
White rice is not a high-potassium food and should not be the first choice for a client with low potassium levels.
Correct Answer is A
Explanation
Choice A rationale:
The nurse should prioritize collecting data from a client who reports unilateral calf pain when ambulating. This symptom could indicate the presence of a deep vein thrombosis (DVT), a potentially life-threatening condition. DVT occurs when a blood clot forms in a deep vein, often in the lower extremities. If left untreated, the clot can dislodge and travel to the lungs, causing a pulmonary embolism. Immediate assessment is crucial to rule out DVT and provide appropriate interventions. The nurse should assess the client's calf for swelling, redness, warmth, and tenderness and may also order diagnostic tests like a duplex ultrasound.
Choice B rationale:
Taking a telephone prescription for a client being transferred from the PACU is important but not the top priority in this situation. While timely transfer and adequate post-operative care are essential, addressing a client with unilateral calf pain and the potential for a DVT takes precedence due to the risk of a life-threatening complication.
Choice C rationale:
Reassuring the partner of a client who sustained a closed head injury is a compassionate action but should not be the first priority. The partner's emotional support can be provided once the immediate medical concerns have been addressed.
Choice D rationale:
Reinforcing a client's dressing on an above-the-knee amputation surgical site is important for the client's post-operative care, but it is not the highest priority when compared to the possibility of a DVT. The nurse should address the client's calf pain first and then attend to the dressing reinforcement.
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