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: Caffeinated beverages can cause diarrhea by stimulating the intestinal motility and increasing the fluid loss. They can also irritate the lining of the stomach and intestines.

Choice B reason: Low-fiber cereal is not likely to cause diarrhea. Fiber helps to bulk up the stool and regulate the bowel movements. Low-fiber foods are often recommended for clients with diarrhea to reduce intestinal activity.

Choice C reason: White rice is not likely to cause diarrhea. It is a bland and starchy food that can help to bind the stool and reduce fluid loss. White rice is often part of the BRAT diet (bananas, rice, applesauce, toast) that is suggested for clients with diarrhea.

Choice D reason: Ripe bananas are not likely to cause diarrhea. They are rich in potassium, which can help to replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help to firm up the stool.

A. Position the client supine. B. Cleanse the perineal area with an antiseptic. C. Deflate the balloon halfway and then pull out the catheter. D. Have the client bear down during removal.

Correct Answer is C

Explanation

Choice A reason: Positioning the client supine is not a necessary action for the nurse to take, as the client can be in any comfortable position for the catheter removal. The nurse should explain the procedure to the client and provide privacy.

Choice B reason: Cleansing the perineal area with an antiseptic is not a required action for the nurse to take, as the catheter is already sterile and the risk of infection is low. The nurse should wear gloves and use a clean syringe to deflate the balloon.

Choice C reason: Deflating the balloon halfway and then pulling out the catheter is the correct action for the nurse to take, as it ensures that the catheter is removed smoothly and without causing trauma to the urethra. The nurse should apply gentle traction and observe the urine color and amount in the drainage bag.

Choice D reason: Having the client bear down during removal is not a recommended action for the nurse to take, as it can cause discomfort and bleeding. The nurse should instruct the client to relax and breathe normally during the procedure.

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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 reinforcing teaching with a client about foods and beverages that can cause diarrhea. Which of the following should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is collecting data on a client who has had diarrhea for several days. Which of the following findings should the nurse expect?

A nurse is reinforcing teaching with a client who has a prescription for home oxygen therapy. Which of the following instructions should the nurse include?

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A nurse is caring for a client who has metabolic alkalosis. Which of the following actions should the nurse take first?

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

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

A charge nurse in a long-term care facility is observing another nurse who is inserting an indwelling urinary catheter into a female client. Which of the following actions by the nurse should prompt the charge nurse to intervene?

A nurse is reinforcing teaching with a client who is at risk for hypokalemia. The nurse should instruct the client that which of the following foods is the best source of potassium?