A nurse is gathering data on a patient who has diarrhea.
Which of the following findings is a sign of hypokalemia?
Hypertension.
Cerebral edema.
Muscle weakness.
Hyperactive bowel sounds.
The Correct Answer is C
Choice A rationale:
Hypertension is not typically a sign of hypokalemia. Hypokalemia, or low potassium levels, can cause symptoms like fatigue, muscle weakness, digestive problems, and frequent urination. Hypertension, or high blood pressure, is not commonly associated with hypokalemia.
Choice B rationale:
Cerebral edema, or swelling in the brain, is not a common symptom of hypokalemia. Hypokalemia is more likely to cause symptoms related to muscle function and digestion, as potassium is an essential mineral that helps regulate muscle contractions, maintain healthy nerve function, and regulate fluid balance.
Choice C rationale:
Muscle weakness is a common symptom of hypokalemia. Potassium helps regulate muscle contractions. When blood potassium levels are low, your muscles produce weaker contractions. This can result in symptoms like muscle weakness and fatigue.
Choice D rationale:
Hyperactive bowel sounds are not typically associated with hypokalemia. Hypokalemia can cause digestive problems, but these are more likely to be issues like constipation rather than increased bowel sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The statement “I do my wheelchair exercises sitting in my chair” is correct. Wheelchair exercises are designed to be performed while seated in a wheelchair. They help to maintain muscle strength and flexibility, which is crucial for individuals with paralysis.
Choice B rationale:
The statement “I use a suppository every night to have a bowel movement” is also correct. Individuals with paralysis often have difficulty with bowel movements due to lack of muscle control. Using a suppository can stimulate the rectum and induce a bowel movement. Choice C rationale:
The statement “I need to catheterize myself twice a day” indicates a need for further teaching. Individuals with paralysis from the waist down following a spinal cord injury typically need to perform intermittent self-catheterization every 4-6 hours, not just twice a day. This helps to prevent urinary tract infections and bladder overdistension.
Choice D rationale:
The statement “I carry a water bottle with me because I drink a lot of water” is correct. Drinking plenty of water is important for overall health and can help to prevent urinary tract infections, which are common in individuals who self-catheterize.
Correct Answer is A
Explanation
Choice A rationale:
The patient does not need to catheterize the stoma multiple times a day. An ileal conduit is a type of urostomy where a small piece of the intestine, called the ileum, is used to create a new passage for urine to leave the body. One end of the ileum is attached to the ureters, and the other end is attached to a small opening in the abdomen, known as a stoma. After the surgery, urine flows from the kidneys, through the ureters and ileal conduit, and out of the stoma. The patient will wear a urostomy pouching system over the stoma to catch and hold the urine. Therefore, the statement “I need to catheterize the stoma multiple times a day” suggests that further instruction is needed because it is not accurate.
Choice B rationale:
The statement “I will need to measure my stoma each week” does not necessarily suggest that further instruction is needed. It is important for patients with an ileal conduit to monitor their stoma regularly for any changes in size, shape, or color, which could indicate complications. However, the frequency of these checks can vary depending on the individual’s condition and the healthcare provider’s instructions.
Choice C rationale:
The statement “I will always have to wear a pouch” is accurate. After the surgery, the patient’s urine will flow from the kidneys, through the ureters and ileal conduit, and out of the stoma. The patient will need to wear a urostomy pouching system over the stoma to catch and hold the urine. Therefore, this statement does not suggest that further instruction is needed.
Choice D rationale:
The statement “I need to clean around the stoma with soap and water” is accurate. It is important for patients with an ileal conduit to keep the skin around the stoma clean to prevent infection and skin irritation. Therefore, this statement does not suggest that further instruction is needed.
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