A nurse is collecting data on a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia?

Hypertension

Cerebral edema

Muscle weakness

Hyperactive bowel sounds

Answer and Explanation

The Correct Answer is C

The correct answer is c. Muscle weakness.

Choice A: Hypertension

Reason: Hypertension, or high blood pressure, is not a typical manifestation of hypokalemia. Hypokalemia primarily affects muscle function and the nervous system. While potassium imbalances can influence blood pressure, hypertension is more commonly associated with hyperkalemia (high potassium levels) rather than hypokalemia.

Choice B: Cerebral Edema

Reason: Cerebral edema, which is swelling of the brain, is not a known manifestation of hypokalemia. Hypokalemia affects muscle and nerve function, but it does not directly cause cerebral edema. This condition is more related to severe head injuries, infections, or other medical conditions.

Choice C: Muscle Weakness

Reason: Muscle weakness is a common and significant manifestation of hypokalemia. Potassium is crucial for muscle function, and low levels can lead to muscle weakness, cramps, and even paralysis in severe cases. This is because potassium helps in the transmission of nerve signals to muscles, and a deficiency disrupts this process.

Choice D: Hyperactive Bowel Sounds

Reason: Hyperactive bowel sounds are not typically associated with hypokalemia. In fact, hypokalemia can lead to decreased bowel motility, resulting in symptoms like constipation or ileus (a condition where the intestines do not move properly). This is due to the role of potassium in muscle contractions, including those in the digestive tract.

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Correct Answer is A

Explanation

Choice A reason: Leakage of urine is a sign of urinary retention, as it indicates that the bladder is overdistended and unable to empty completely. The urine may leak around the urethra or through a catheter.

Choice B reason: Dark-colored urine is not a sign of urinary retention. It can be caused by dehydration, certain foods or medications, or liver or kidney problems.

Choice C reason: Cloudy urine is not a sign of urinary retention. It can be caused by infection, inflammation, or stones in the urinary tract.

Choice D reason: Blood in urine is not a sign of urinary retention. It can be caused by trauma, infection, cancer, or coagulation disorders in the urinary tract.

A. Confirm the client's identity by checking their wristband. B. Provide for the client's privacy by closing the curtains. C. Assist the client into the Sims' position. D. Insert the tip of the enema tubing into the client's rectum.

Correct Answer is A,B,C,D

Explanation

Choice A reason: Confirming the client's identity by checking their wristband is the first step to ensure that the right client receives the right treatment.

Choice B reason: Providing for the client's privacy by closing the curtains is the second step to respect the client's dignity and comfort.

Choice C reason: Assisting the client into the Sims' position is the third step to facilitate the insertion of the enema tubing and the flow of the solution. The Sims' position is a side-lying position with the upper leg flexed and the lower leg straight.

Choice D reason: Inserting the tip of the enema tubing into the client's rectum is the fourth and final step to administer the enema. The nurse should lubricate the tip of the tubing, gently insert it about 3 to 4 inches into the rectum, and release the clamp to allow the solution to flow. The nurse should monitor the client for any signs of discomfort or cramping and adjust the flow rate accordingly.

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A nurse is collecting data on a client who has diarrhea. Which of the following findings is a manifestation of hypokalemia?

Choice A: Hypertension

Choice B: Cerebral Edema

Choice C: Muscle Weakness

Choice D: Hyperactive Bowel Sounds

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

A nurse is caring for a client who reports constipation. The provider has prescribed an enema. Identify the sequence of steps the nurse should take to administer the enema. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is A,B,C,D

Explanation

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