A nurse is evaluating the effectiveness of fluid therapy for a client who has hypernatremia. Which of the following findings indicates improvement? (Select all that apply.)
Decreased thirst.
Increased urine output.
Decreased serum sodium level.
Increased level of consciousness.
Decreased edema.
Correct Answer : A,B,C,D
Choice A reason:
Decreased thirst. This is a sign of improvement because hypernatremia causes increased thirst due to high sodium levels in the blood. Decreased thirst indicates that the fluid therapy has restored the normal balance of sodium and water in the body.
Choice B reason:
Increased urine output. This is a sign of improvement because hypernatremia can cause decreased urine output due to dehydration or kidney dysfunction. Increased urine output indicates that the fluid therapy has replenished the body's water and helped the kidneys excrete excess sodium.
Choice C reason:
Decreased serum sodium level. This is a sign of improvement because hypernatremia is defined as a serum sodium level higher than 145 mEq/L. Decreased serum sodium level indicates that the fluid therapy has diluted the blood and lowered the sodium concentration to within the normal range.
Choice D reason:
Increased level of consciousness. This is a sign of improvement because hypernatremia can cause confusion, lethargy, or coma due to the effects of high sodium levels on the brain. Increased level of consciousness indicates that the fluid therapy has improved the brain function and reduced the risk of brain injury.
Choice E reason:
Decreased edema. This is not a sign of improvement because hypernatremia does not cause edema, which is the accumulation of fluid in the interstitial spaces. Edema is more likely to occur in conditions such as hypervolemia (excess fluid volume) or hyponatremia (low sodium levels) Decreased edema may indicate that the fluid therapy has caused fluid overload or electrolyte imbalance, which can be harmful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
U waves are not a sign of high potassium level, but rather of low potassium level (hypokalemia) Hypokalemia can cause ST segment depression, T wave flattening or inversion, and prominent U waves.
Choice B reason:
Absent P waves are not a sign of high potassium level, but rather of a severe conduction block or atrial fibrillation. High potassium level can cause P wave widening or flattening, and PR prolongation, but not complete disappearance of P waves.
Choice C reason:
Elevated T waves are the most common and earliest sign of high potassium level (hyperkalemia) Hyperkalemia can cause tall, peaked, symmetric T waves that may merge with the QRS complex. This is the correct answer.
Choice D reason:
Inverted QRS complexes are not a sign of high potassium level, but rather of ventricular arrhythmias or myocardial infarction. High potassium level can cause QRS widening and bizarre QRS morphology, but not inversion.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason:
Jugular vein distension is a sign of fluid overload because it indicates increased pressure in the right atrium and superior vena cava due to excess blood volume.
Choice B reason:
Weight gain of 2 kg in one day is a sign of fluid overload because it reflects fluid retention in the body. A weight gain of 1 kg (2.2 lb) is equivalent to 1 L of fluid.
Choice C reason:
Decreased hematocrit is a sign of fluid overload because it indicates hemodilution or dilution of the blood due to excess fluid in the intravascular space.
Choice D reason:
Bounding pulse is a sign of fluid overload because it reflects increased cardiac output and stroke volume due to excess blood volume.
Choice E reason:
Flat neck veins are not a sign of fluid overload, but rather a sign of fluid deficit or dehydration. In fluid overload, neck veins will be distended or elevated.
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