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 ["A","C","E"]
Explanation
Choice A reason:
Administer magnesium sulfate IV. This is correct because magnesium sulfate is the treatment of choice for severe hypomagnesemia. It can rapidly increase the blood level of magnesium and correct the symptoms of deficiency.
Choice B reason:
Monitor the client's blood pressure and heart rate. This is incorrect because monitoring vital signs is not a specific intervention for hypomagnesemia. However, it is important to monitor the client for signs of hypotension and bradycardia, which can occur as adverse effects of magnesium sulfate therapy.
Choice C reason:
Encourage the client to increase intake of green leafy vegetables. This is correct because green leafy vegetables are rich sources of dietary magnesium. Increasing the intake of magnesium-rich foods can help prevent or treat mild hypomagnesemia.
Choice D reason:
Prepare to administer calcium gluconate IV. This is incorrect because calcium gluconate is not indicated for hypomagnesemia. Calcium gluconate is used to treat hypocalcemia, which can occur as a complication of hypomagnesemia. However, calcium gluconate should not be given until the magnesium level is corrected, as low magnesium can impair the response to calcium.
Choice E reason:
Assess the client for Chvostek's sign and Trousseau's sign. This is correct because Chvostek's sign and Trousseau's sign are clinical tests for neuromuscular irritability, which can occur in hypomagnesemia. Chvostek's sign is elicited by tapping the facial nerve in front of the ear and observing for facial twitching. Trousseau's sign is elicited by inflating a blood pressure cuff above the systolic pressure for 3 minutes and observing for carpal spasm.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution, not a hypotonic one. Isotonic solutions have the same concentration of solutes as blood plasma and do not cause fluid movement across the cell membrane.
Choice B reason:
This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution, not a hypertonic one. Hypertonic solutions have a higher concentration of solutes than blood plasma and cause fluid to move out of the cells and into the vascular space.
Choice C reason:
This is correct because 0.9% sodium chloride (normal saline) is an isotonic solution that will expand the vascular space by adding fluid without changing the concentration of solutes. This is useful for patients with hyponatremia (low sodium level in the blood) who need to restore their fluid and electrolyte balance.
Choice D reason:
This is incorrect because 0.9% sodium chloride (normal saline) is an isotonic solution that will expand the vascular space by adding fluid without changing the concentration of solutes. It will not have no effect on fluid movement, as it will increase the intravascular volume.
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