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 C
Explanation
Choice A rationale:
The nurse should not instruct the client to rest with the legs above heart level. While elevating the legs can be helpful for managing symptoms of peripheral artery disease (PAD), it is not a suitable choice for older adults, especially those with heart conditions. It can put additional strain on the heart and may not be appropriate for all clients. Elevation of the legs should be done with caution and under healthcare provider guidance.
Choice B rationale:
The nurse should not advise the client to wear antiembolic stockings during the day. Antiembolic stockings, also known as compression stockings, are primarily used for venous insufficiency and the prevention of deep vein thrombosis (DVT). They may not be effective or necessary for the management of PAD. It's important to tailor the instructions to the specific condition, and in the case of PAD, other strategies may be more appropriate.
Choice C rationale:
The correct answer is choice C. The nurse should instruct the client to adjust the thermostat so that the environment is warm. This is an important recommendation for clients with PAD because keeping the extremities warm can help improve circulation and reduce symptoms. Cold environments can exacerbate the vasoconstriction associated with PAD, leading to more discomfort. Maintaining a warm environment is a simple and effective measure for symptom management.
Choice D rationale:
The nurse should not recommend applying a heating pad on a low setting to help relieve leg pain. While heat can provide temporary relief for muscle pain, it may not be the best option for clients with PAD. Applying heat directly to the affected area can sometimes lead to burns or skin damage, especially in older adults who may have decreased sensation. Heat should be used cautiously, and other methods like keeping the environment warm are preferred.
Correct Answer is B
Explanation
Choice A rationale:
Extreme thirst is not a typical finding in a client with hypokalemia. Hypokalemia is an electrolyte imbalance that can lead to symptoms like weakness and irregular heartbeats, but extreme thirst is not a direct result of low potassium levels.
Choice B rationale:
"Weak, irregular pulse" is the correct response. Hypokalemia can lead to cardiac arrhythmias, which may manifest as a weak, irregular pulse. Potassium plays a crucial role in maintaining the electrical activity of the heart, and low levels can disrupt normal heart rhythms.
Choice C rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. Instead, you might expect diminished or absent bowel sounds in severe cases due to muscle weakness.
Choice D rationale:
Hyperactive reflexes are not typically associated with hypokalemia. Instead, hypokalemia can lead to muscle weakness and potentially even paralysis in severe cases.
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