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 C

Explanation

A. Using patterned-paced breathing is typically associated with labor pain management rather than postoperative pain following a cesarean birth. While controlled breathing can help with discomfort, it is not the most effective strategy for incision-related pain.

B. Changing positions as little as possible is incorrect. Early mobility is encouraged after a cesarean birth to promote circulation, prevent complications like deep vein thrombosis, and aid recovery. Avoiding movement can lead to stiffness and prolonged discomfort.

C. Splinting the incision with a pillow is correct. Holding a pillow firmly against the incision while changing positions provides support, reduces strain on the abdominal muscles, and minimizes pain during movement.

D. Applying counterpressure to the back is incorrect. Counterpressure is a technique used for back labor pain during childbirth and is not relevant for post-cesarean incision pain.

A. Heart rhythm B. Urinary output C. Pain sensation D. Muscle strength

Correct Answer is A

Explanation

A. Heart rhythm: This is correct. Hypothermia, indicated by a body temperature of 32.5°C (90.5°F), can affect the cardiovascular system, potentially causing arrhythmias or even cardiac arrest. Monitoring heart rhythm is critical because of the risk of life-threatening cardiac complications associated with severe hypothermia.

B. Urinary output: While urinary output may decrease in hypothermic conditions due to vasoconstriction, it is not the priority. Cardiac function takes precedence, as severe hypothermia can lead to fatal arrhythmias.

C. Pain sensation: Although decreased pain sensation can occur in hypothermia, it is less urgent to monitor compared to the potential for life-threatening arrhythmias or cardiac arrest.

D. Muscle strength: While hypothermia can impair muscle strength, it is not the priority compared to monitoring for cardiac irregularities, which can be fatal if left unchecked.

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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

Naxlex Comprehensive Predictor Exams

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