A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?
Muscle cramps
Constipation
Blurred vision
Hypertension
The Correct Answer is A
The correct answer is A. Muscle cramps. Hyponatremia is a condition where sodium levels in the blood are lower than normal, which can cause water to move into body cells and make them swell. This can affect muscle cells and cause cramps, spasms or weakness. The other options are not typical signs of hyponatremia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Urine output: At 1400, the client had oliguria (20 mL/hr). Magnesium is primarily excreted by the kidneys; if urine output is low, magnesium levels can rise to toxic levels. An increase to 40 mL/hr (exceeding the standard minimum threshold of 30 mL/hr) indicates improved renal perfusion and the body's ability to clear the magnesium, reversing the toxicity.
Deep tendon reflexes (DTR):At 1400, the client had diminished reflexes (1+), which is concerning in the context of magnesium sulfate therapy, as it can indicate magnesium toxicity. At 1800, reflexes are 2+, which is normal and shows improvement.
Heart rate:At 1400, the client had bradycardia (heart rate 58 bpm). By 1800, the heart rate had normalized to 78 bpm, indicating an improvement.
Other findings:
Temperature 38.3°C (101°F):This indicates a fever, which is not a sign of improvement.
Blood pressure 146/96 mm Hg:Although this is better than a severely hypertensive reading, it is still elevated.
Correct Answer is C
Explanation
The correct answer is C. Hearing voices is a common symptom of psychotic disorders, such as schizophrenia. The nurse should first assess if the client is at risk of harming themselves or others due to the content of the voices. This is a priority intervention that can help prevent potential violence or suicide. The other statements are not appropriate as initial responses. A walk outside may not stop the voices and may expose the client to more stimuli that could worsen their condition. Asking the client to listen to the nurse instead of the voices may be perceived as dismissive or challenging by the client. Acknowledging that the voices are real to the client but not to the nurse may help establish rapport, but it does not address the urgency of assessing for safety.
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