A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect?

Nausea and vomiting

Altered mental status

Dysrhythmias

Hypothermia

Answer and Explanation

The Correct Answer is B

A. Nausea and vomiting: Nausea and vomiting can be present with hypernatremia (high sodium levels), but they are not the most prominent or specific symptom. The client may experience these symptoms, but they are usually accompanied by other signs.

B. Altered mental status: This is a common manifestation of hypernatremia. The elevated sodium level causes an osmotic imbalance, leading to water shifting out of cells, which results in neurological symptoms, including confusion, lethargy, or seizures.

C. Dysrhythmias: Dysrhythmias can occur with electrolyte imbalances, including hypernatremia, but the primary symptoms related to sodium levels are more often neurological in nature, such as confusion or altered mental status, rather than dysrhythmias specifically.

D. Hypothermia: Hypernatremia typically causes an increase in body temperature, not hypothermia. Elevated sodium levels cause dehydration, which could contribute to increased body temperature rather than cooling.

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Correct Answer is D

Explanation

A. Arms raised above her head with her legs elevated on pillows: This is not an appropriate position for a lumbar puncture. The positioning is not ideal for access to the lumbar region and would be uncomfortable for the client.

B. Prone with her arms at her side and her legs extended: While this position may be used for certain procedures, it is not the most appropriate position for a lumbar puncture, which requires specific spinal positioning to access the subarachnoid space effectively.

C. Trendelenburg with her body in Sims' position: Trendelenburg involves positioning the client with the head lower than the feet, which is not necessary for a lumbar puncture and could interfere with the procedure. The Sims' position is more suited for certain other procedures.

D. Head flexed to the chest and her knees pulled up to the abdomen: This is correct. The client should be in a fetal position, with the head flexed toward the chest and the knees pulled up toward the abdomen. This position helps to widen the intervertebral spaces and facilitates easier access for the lumbar puncture.

A. Contact the provider within 48 hr to obtain a prescription for the restraints. B. Remove the restraints from the client's wrists every 2 hr. C. Check that one finger will fit between the client's wrists and the restraints. D. Fasten the restraints' ties to the bed's side rails.

Correct Answer is B

Explanation

A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.

B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.

C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.

D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.

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A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect?

Nursing Test Bank

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