A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?
Restlessness
Hyperactive bowel sounds
Decreased deep-tendon reflexes
Bounding peripheral pulses
The Correct Answer is C
A. Restlessness:
Restlessness is not typically associated with hypokalemia. Instead, it may indicate anxiety, discomfort, or other factors unrelated to electrolyte imbalances.
B. Hyperactive bowel sounds:
Hyperactive bowel sounds are often associated with increased gastrointestinal motility, which may occur in conditions such as diarrhea or gastroenteritis. While electrolyte imbalances can contribute to gastrointestinal symptoms, hyperactive bowel sounds are not specific to hypokalemia.
C. Decreased deep-tendon reflexes:
Hypokalemia can lead to decreased deep-tendon reflexes due to its effects on nerve conduction. Potassium is essential for proper nerve and muscle function, and low levels can impair reflexes.
D. Bounding peripheral pulses:
Bounding peripheral pulses are not typically associated with hypokalemia. Instead, they may indicate increased cardiac output or volume overload, which can occur in conditions such as heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Headache:
Headache is not typically a clinical manifestation of an acute myocardial infarction. The more common symptoms are related to chest pain, autonomic responses, and cardiovascular changes.
B. Tachycardia:
Tachycardia, or an increased heart rate, is a common symptom during an acute MI. This occurs as the body attempts to compensate for decreased cardiac output and perfusion.
C. Nausea:
Nausea is a frequent symptom associated with an acute MI. It results from the activation of the autonomic nervous system during the heart attack.
D. Diaphoresis:
Diaphoresis, or excessive sweating, is a classic symptom of an acute MI. It occurs due to the sympathetic nervous system's response to pain and stress from the heart attack.
E. Orthopnea:
Orthopnea, or difficulty breathing when lying down, is more commonly associated with congestive heart failure rather than an acute MI. While shortness of breath can occur during an MI, orthopnea is not a primary manifestation.
Correct Answer is C
Explanation
Answer: C. Respiratory acidosis
Rationale:
A) Metabolic acidosis: This occurs when there is an excess of acid in the body or a loss of bicarbonate, often due to conditions such as renal failure or severe diarrhea. In chronic bronchitis, the primary issue is related to respiratory function rather than metabolic disturbances.
B) Respiratory alkalosis: This condition results from hyperventilation, leading to excessive loss of carbon dioxide. It is unlikely in a client with chronic bronchitis, who typically experiences difficulty in exhaling fully rather than hyperventilating.
C) Respiratory acidosis: In chronic bronchitis, airflow obstruction and reduced gas exchange can lead to carbon dioxide retention, resulting in respiratory acidosis. Symptoms like dyspnea and increased work of breathing support this imbalance, as the body is unable to adequately expel carbon dioxide.
D) Metabolic alkalosis: This imbalance results from excessive bicarbonate or loss of hydrogen ions, often related to prolonged vomiting or diuretics. It is not characteristic of chronic bronchitis, where the primary concern is respiratory function rather than metabolic processes.
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