A nurse is collecting data from a client who has hyponatremia.
Which of the following findings should the nurse expect?

Hypertension.

Constipation.

Muscle cramps.

Blurred vision.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Hypertension (high blood pressure) is not typically associated with hyponatremia. Hyponatremia is characterized by low levels of sodium in the blood, which can lead to symptoms such as headache, nausea, vomiting, confusion, and muscle cramps. Hypertension is more commonly associated with conditions like hypertension itself or conditions that cause fluid retention.

Choice B rationale:

Constipation is not a typical finding in hyponatremia. Hyponatremia is more likely to cause gastrointestinal symptoms such as nausea and vomiting. Constipation is not a direct consequence of low sodium levels in the blood.

Choice C rationale:

Muscle cramps are a common manifestation of hyponatremia. Low sodium levels can lead to an imbalance in electrolytes, affecting muscle function and leading to muscle cramps and weakness. Monitoring for muscle cramps is important in clients with hyponatremia.

Choice D rationale:

Blurred vision is not a classic symptom of hyponatremia. Hyponatremia is more likely to cause neurological symptoms such as confusion, headache, and in severe cases, seizures. Blurred vision is typically associated with other eye or visual disorders and not directly related to low sodium levels in the blood.

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Correct Answer is D

Explanation

Choice A rationale:

Asking, "What makes you think the staff is following you?" is a confrontational approach and may not be helpful in building rapport or addressing the client's paranoid beliefs. It can come across as dismissive and may exacerbate the client's anxiety.

Choice B rationale:

Telling the client, "The psychiatric staff is not FBI. They are here to help you," is a straightforward response but may not effectively address the client's concerns or build rapport. It does not acknowledge the client's feelings and may not be well-received.

Choice C rationale:

Asking, "Why do you feel the staff is the FBI?" is a more open-ended and therapeutic approach. It encourages the client to express their thoughts and feelings, providing an opportunity for the nurse to better understand the client's perspective.

Choice D rationale:

Saying, "This must be very frightening for you. Let's talk more about it," is the most empathetic and client-centered response. It acknowledges the client's emotions and offers support. It also opens the door for further discussion and therapeutic communication, allowing the nurse to explore the client's fears and concerns in a non-confrontational manner.

A. A nurse observes another nurse remove wrist restraints one at a time from a client who is currently calm. B. A nurse discovers that an electronic IV pump delivered twice the prescribed amount of fluid to a client. C. A nurse discovers that a client's family member has administered a PCA dose. D. A nurse observes a client vomiting after receiving an oral pain medication.

Correct Answer is B

Explanation

Choice A rationale:

Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.

Choice B rationale:

An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.

Choice C rationale:

Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.

Choice D rationale:

Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.

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A nurse is collecting data from a client who has hyponatremia.Which of the following findings should the nurse expect?

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A nurse is collecting data from a client who has hyponatremia.
Which of the following findings should the nurse expect?