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

The correct answer is b. Decreased deep tendon reflexes.

Choice A: Wheezing

Reason: Wheezing is typically associated with respiratory conditions such as asthma, chronic obstructive pulmonary disease (COPD), or allergic reactions. It is not a common manifestation of hyperkalemia. Hyperkalemia primarily affects the muscular and cardiovascular systems rather than the respiratory system.

Choice B: Decreased deep tendon reflexes

Reason: Hyperkalemia can cause neuromuscular symptoms, including muscle weakness and decreased deep tendon reflexes. High potassium levels interfere with the normal function of muscle cells and nerves, leading to these symptoms. This is a direct result of the altered action potentials in neurons caused by elevated potassium levels.

Choice C: Hypoactive bowel sounds

Reason: Hypoactive bowel sounds are generally associated with conditions that cause decreased gastrointestinal motility, such as ileus or bowel obstruction. While hyperkalemia can affect muscle function, it is more likely to cause hyperactive bowel sounds due to increased gastrointestinal motility rather than hypoactive sounds.

Choice D: Cerebral edema

Reason: Cerebral edema is swelling of the brain and is not a typical manifestation of hyperkalemia. It is more commonly associated with conditions such as traumatic brain injury, stroke, or severe infections. Hyperkalemia primarily affects the heart and muscles.

Choice A reason: Requesting that the provider prescribe a stool softener is not the best action for the nurse to take, as it may cause dependency, dehydration, or electrolyte imbalance. The nurse should try non-pharmacological interventions first, such as increasing fluid and fiber intake, promoting physical activity, and establishing a regular bowel routine.

Choice B reason: Adding fluid and fiber to the diet is the best action for the nurse to take, as it helps to soften the stool, increase the bulk, and stimulate peristalsis. The nurse should encourage the client to drink at least 2 liters of water per day and eat foods rich in fiber, such as fruits, vegetables, and whole grains.

Choice C reason: Promoting active range-of-motion activities is a good action for the nurse to take, as it helps to improve circulation, muscle tone, and bowel motility. The nurse should assist the client to perform exercises that are appropriate for their level of mobility and endurance.

Choice D reason: Avoiding gas-producing foods is not a necessary action for the nurse to take, as it does not directly affect constipation. Gas-producing foods, such as beans, cabbage, and broccoli, may cause bloating and discomfort, but they do not cause or worsen constipation.