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

Choice A reason: Cerebral edema is not typically a manifestation of hyperkalemia. Hyperkalemia can cause neurological symptoms due to its effect on nerve transmission, but cerebral edema is more commonly associated with conditions like traumatic brain injury, stroke, or brain tumors.

Choice B reason: Wheezing is a respiratory symptom and is not directly related to hyperkalemia. It is more commonly associated with respiratory conditions such as asthma or chronic obstructive pulmonary disease (COPD).

Choice C reason: Hypoactive bowel sounds may indicate a gastrointestinal issue but are not a specific sign of hyperkalemia. Hyperkalemia can affect smooth muscle contraction and could potentially lead to intestinal motility issues, but this is not a primary manifestation.

Choice D reason: Decreased deep tendon reflexes can be a manifestation of hyperkalemia. Hyperkalemia affects the neuromuscular junction and can lead to muscle weakness, which may manifest as decreased reflexes. Normal potassium levels in the blood are typically between 3.5 and 5.0 millimoles per liter (mmol/L). Hyperkalemia occurs when potassium levels rise above 5.5 mmol/L.

Answer: B

Rationale:

A. "You should expect your stoma to be a purple color": A healthy stoma should be pink or red in color. A purple or dark-colored stoma may indicate poor blood flow and could be a sign of complications requiring immediate medical attention.

B. "You will have a stoma in your left lower abdomen": For a sigmoid colostomy, the stoma is typically located in the left lower quadrant of the abdomen. This placement is consistent with the nature of the procedure and is a correct and important piece of information for preoperative teaching.

C. "Your colostomy will not produce formed stool": A sigmoid colostomy usually results in the production of more formed stool because it is located closer to the rectum, where most of the water has been absorbed. Expecting unformed stool is more typical of a colostomy in the ascending or transverse colon.

D. "The end of the stoma will be painful after this procedure": While some discomfort is normal postoperatively, the stoma itself should not be persistently painful. Pain management and proper care should be addressed, but ongoing severe pain could indicate complications.