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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You should not palpate your child's abdomen prior to surgery." is correct. Palpating the abdomen of a child with Wilms' tumor should be avoided, as this could cause the tumor to rupture and spread cancerous cells. The tumor is typically confined to one kidney and must be surgically removed.
B. "Your child should have surgery in 7 to 10 days to remove the tumor." is incorrect. Surgery to remove a Wilms' tumor typically occurs within 24 to 48 hours after diagnosis, not within 7 to 10 days.
C. "You should give your child captopril 200 mg PO daily." is incorrect. Captopril is not a standard medication used in the treatment of Wilms' tumor. Treatment often involves surgery, chemotherapy, and sometimes radiation therapy.
D. "Your child will not require further treatment after removal of the tumor." is incorrect. Post-surgical treatment, such as chemotherapy and/or radiation therapy, is often required, depending on the stage and extent of the tumor.
Correct Answer is A
Explanation
A. Telling the APs to stop the conversation is correct. Discussing client information in a public area violates HIPAA (Health Insurance Portability and Accountability Act) privacy regulations. The nurse should immediately intervene and remind the APs about maintaining client confidentiality.
B. Documenting the event in the client's progress notes is incorrect. Client progress notes should contain only information relevant to client care. Documenting an overheard conversation about a privacy violation does not belong in the medical record.
C. Informing the client of the APs' actions is incorrect. While privacy is essential, informing the client may cause unnecessary distress. The nurse should focus on correcting the behavior of the APs rather than alarming the client.
D. Submitting an incident report to the risk manager is incorrect. While some breaches of confidentiality require reporting, the first step is to address the issue directly with the APs. If the behavior continues or is severe, reporting to a supervisor may be necessary.
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