A nurse is teaching a client who has heart failure about the renin-angiotensin-aldosterone system. Which of the following statements by the client indicates an understanding of the teaching?
"This system helps to increase my blood pressure when it is too low.”
"This system helps to decrease my blood volume when it is too high.”
"This system helps to regulate my blood pH when it is too acidic.”
"This system helps to lower my potassium level when it is too high."
The Correct Answer is A
Choice A reason:
This system helps to increase my blood pressure when it is too low. This is correct because the renin-angiotensin-aldosterone system (RAAS) is a mechanism that regulates arterial blood pressure by increasing sodium and water retention, vasoconstriction, and cardiac output.
Choice B reason:
This system helps to decrease my blood volume when it is too high. This is incorrect because the RAAS does the opposite of this. It increases blood volume by stimulating the secretion of aldosterone, which causes the kidneys to reabsorb sodium and water.
Choice C reason:
This system helps to regulate my blood pH when it is too acidic. This is incorrect because the RAAS does not directly affect blood pH. Blood pH is regulated by the respiratory and renal systems, which adjust the levels of carbon dioxide and bicarbonate in the blood.
Choice D reason:
This system helps to lower my potassium level when it is too high. This is incorrect because the RAAS does not directly lower potassium levels. Potassium levels are regulated by the kidneys, which excrete excess potassium in the urine. However, aldosterone, which is part of the RAAS, can indirectly affect potassium levels by increasing sodium reabsorption and potassium secretion in the distal tubules of the kidneys.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
A positive Chvostek's sign is a facial twitch that occurs when the facial nerve is tapped. This is a sign of hypocalcemia, which causes increased neuromuscular excitability. According to index 2, a nurse can assess for Chvostek's sign by tapping the cheek just below the temple. If the facial muscles contract, the sign is positive.
Choice B reason:
Decreased deep tendon reflexes are not a sign of hypocalcemia, but rather of hypercalcemia, which causes decreased neuromuscular excitability. According to index 5, symptoms of hypercalcemia include muscle weakness, fatigue, constipation, nausea, vomiting, and confusion.
Choice C reason:
Muscle weakness is also not a sign of hypocalcemia, but rather of hyperkalemia, which causes impaired muscle contraction. According to index 1, a nurse can assess for muscle weakness by testing the client's grip strength and ability to lift the legs against resistance. If the client has difficulty performing these tasks, they may have hyperkalemia.
Choice D reason:
Hypoactive bowel sounds are not a sign of hypocalcemia, but rather of ileus, which is a paralysis of the intestinal muscles that causes obstruction. Ileus can be caused by various factors, such as surgery, infection, medication, or electrolyte imbalance. According to index 6, symptoms of ileus include abdominal pain, distension, nausea, vomiting, and constipation.
Correct Answer is C
Explanation
Choice A reason:
Tachycardia is not a sign of magnesium toxicity. Magnesium sulfate can cause bradycardia or slow heart rate as a side effect.
Choice B reason:
Diarrhea is not a sign of magnesium toxicity. Magnesium sulfate can cause constipation or decreased bowel movements as a side effect.
Choice C reason:
Respiratory depression is a sign of magnesium toxicity. Magnesium sulfate can cause decreased respiratory rate or difficulty breathing as a side effect. This is a serious complication that requires immediate intervention by the nurse, such as discontinuing the infusion and administering calcium gluconate as an antidote.
Choice D reason:
Hyperthermia is not a sign of magnesium toxicity. Magnesium sulfate can cause hypothermia or low body temperature as a side effect.
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