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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Applying a cold compress to the client's calf is not the priority in this situation. The client is reporting pain in the calf, which could be indicative of deep vein thrombosis (DVT), a potentially serious condition. Monitoring the client's oxygen saturation (pulse oximetry) is a more appropriate action to assess for possible DVT complications, such as a pulmonary embolism.
Choice B rationale:
Monitoring the client's pulse oximetry is the correct action in this scenario. Pain in the calf can be a symptom of DVT, which can lead to reduced blood flow and potential oxygenation issues. Monitoring the client's oxygen saturation levels can help identify any oxygenation problems early.
Choice C rationale:
Instructing the client to massage the calf gently is not recommended in this situation, as it may dislodge a clot if DVT is present. Massaging the calf can be harmful and is contraindicated when DVT is suspected.
Choice D rationale:
Maintaining the leg in a dependent position while in bed is not a recommended action in this case. Elevating the leg can help reduce swelling and improve venous return, but it should be done cautiously, especially if DVT is suspected. Monitoring the client's condition and oxygen saturation takes precedence.
Correct Answer is ["C","D"]
Explanation
The correct answers are C and D.
Choice A reason: Preferred bath time is a personal preference and comfort-related aspect of patient care. While it is important for overall patient satisfaction and care planning, it is not critical information for a change-of-shift report following a total knee arthroscopy. The focus in such reports is typically on clinical status, immediate care needs, and potential complications.
Choice B reason: Admission vital signs are the initial measurements taken upon the patient’s admission to the healthcare facility. These are baseline values that can be referenced later to note any significant changes. However, for a change-of-shift report, especially 2 days postoperative, the most current vital signs and any changes since surgery are more pertinent than the admission values.
Choice C reason: The time of the last pain medication is crucial information for a change-of-shift report. Pain management is a key aspect of postoperative care, particularly after procedures like total knee arthroscopy. Knowing when the last dose was administered helps the incoming nurse manage the patient’s pain effectively and anticipate when the next dose is due.
Choice D reason: The steps required for dressing change are essential to include in the change-of-shift report. Proper wound care and dressing changes are vital to prevent infection and ensure proper healing after surgery. Detailed instructions on the dressing change process help maintain consistency in care between different caregivers.
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