An elderly patient has been having copious vomiting for several days and has become lethargic and weak. His mucous membranes are dry.

He has poor skin turgor.

Lab work shows: sodium of 145, ABGs: pH 7.58, PCO2 38, HCO3 38, PO2 95, SO2 98. Which response best explains the patient’s lethargy and weakness?

The hypokalemia brought on severe muscle spasms, causing exhaustion.

Due to his low potassium, his cells rely on glycolysis.

Due to the hypokalemia, his cells are hyperpolarized.

The hypernatremia caused cellular dehydration, leading to lethargy.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Hypokalemia can cause muscle weakness and cramps, but it does not typically lead to severe muscle spasms causing exhaustion. The patient’s symptoms of lethargy and weakness are more likely related to electrolyte imbalances and dehydration rather than muscle spasms.
Choice B rationale
While low potassium levels can affect cellular metabolism, the primary issue here is not glycolysis. The patient’s symptoms are more consistent with dehydration and electrolyte imbalances rather than a metabolic shift to glycolysis.
Choice C rationale
Hypokalemia can cause cells to become hyperpolarized, leading to muscle weakness and decreased reflexes. However, the patient’s symptoms of lethargy and weakness are more likely due to dehydration and electrolyte imbalances rather than cellular hyperpolarization.
Choice D rationale
Hypernatremia, or high sodium levels, can cause cellular dehydration, leading to symptoms such as lethargy and weakness. The patient’s lab results and clinical presentation are consistent with hypernatremia-induced cellular dehydration, which explains his symptoms.

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Correct Answer is C

Explanation

Choice A rationale
Administering diuretic medication as prescribed is an important intervention for managing fluid overload in heart failure. Diuretics help reduce fluid accumulation by increasing urine output, which can alleviate symptoms such as swelling and shortness of breath. However, before administering any medication, it is crucial to assess the client’s current respiratory status and oxygen saturation to determine the severity of their condition and ensure that the intervention is appropriate and safe.
Choice B rationale
Elevating the client’s legs can help reduce swelling in the lower extremities by promoting venous return and decreasing fluid accumulation. While this intervention can provide some relief, it does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.
Choice C rationale
Assessing the client’s respiratory status and oxygen saturation is the first priority in this scenario. Heart failure can lead to pulmonary congestion and impaired gas exchange, resulting in shortness of breath and decreased oxygen levels. By assessing the client’s respiratory status and oxygen saturation, the nurse can determine the severity of the client’s condition, identify any immediate respiratory needs, and implement appropriate interventions to improve oxygenation and respiratory function.
Choice D rationale
Restricting fluid intake is a common intervention for managing fluid overload in heart failure. By limiting fluid intake, the nurse can help prevent further fluid accumulation and reduce the risk of worsening symptoms. However, this intervention does not address the immediate concern of the client’s respiratory status. Assessing the client’s respiratory status and oxygen saturation is a priority to ensure that they are receiving adequate oxygenation and to identify any potential respiratory distress that may require urgent intervention.

A. Hypocortisolism. B. Hyperinsulinemia. C. Iodide deficiency. D. Azotemia.

Correct Answer is C

Explanation

Choice A rationale
Hypocortisolism, also known as Addison’s disease, is characterized by insufficient production of cortisol by the adrenal glands. It does not typically cause goiter, which is an enlargement of the thyroid gland due to various causes such as iodine deficiency, autoimmune diseases, or nodules.
Choice B rationale
Hyperinsulinemia refers to an excess level of insulin in the blood, often associated with insulin resistance and type 2 diabetes. It is not related to the development of goiter.
Choice C rationale
Iodide deficiency is a common cause of goiter. The thyroid gland requires iodine to produce thyroid hormones. When there is a deficiency, the gland enlarges in an attempt to capture more iodine from the bloodstream.
Choice D rationale
Azotemia is an elevation of blood urea nitrogen (BUN) and serum creatinine levels, typically due to kidney dysfunction. It is not associated with the development of goiter.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure is experiencing shortness of breath and swelling in the lower extremities. Which of the following interventions should the nurse implement first?

Correct Answer is C

Explanation

A goiter is often associated with:

Correct Answer is C

Explanation

A man, diagnosed with alcoholic liver disease and cirrhosis, presents to his healthcare provider for treatment. He is complaining of increased blood glucose, blurred vision, and cannot remember his birth date or age. The nurse notes that he has asterixis. These signs are most likely due to:

A nurse is caring for a client with chronic kidney disease (CKD) who has elevated intracranial pressure (ICP). While assessing the client, the nurse hears crackles in the lungs and notes a decrease in urine output.Which complication has the client likely developed?

A nurse has identified a fluid volume deficit in the patient who has suffered prolonged vomiting and diarrhea. Which assessment data is most important in identifying that the patient may be developing prerenal acute kidney injury (AKI)?

A nurse caring for a patient with unstable angina will most likely need to give medications to accomplish which desirable objective?

A client with a history of hypertension is admitted with a severe headache and blurred vision. Which of the following findings would indicate a hypertensive crisis?

Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?

A nurse is providing education to a client with newly diagnosed type 2 diabetes mellitus. Which statement by the client indicates a need for further teaching?

A nurse is assessing a client with chronic obstructive pulmonary disease (COPD). Which of the following findings would indicate the need for immediate intervention?