An older adult nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?

Hypercalcemia

Hypomagnesemia

Hyponatremia

Hypernatremia

Answer and Explanation

The Correct Answer is C

A. Hypercalcemia: Hypercalcemia may cause confusion but is less likely associated with dehydration.

B. Hypomagnesemia: This can cause neuromuscular symptoms but is less commonly linked to confusion in dehydration.

C. Hyponatremia: Low sodium levels disrupt brain cell function, leading to confusion and neurological symptoms, which are common in dehydrated older adults.

D. Hypernatremia: While dehydration may cause hypernatremia, it is less likely to present with confusion in this context compared to hyponatremia.

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Correct Answer is B

Explanation

A. Cullen's sign: Cullen's sign is a bluish discoloration around the umbilicus, indicating possible internal bleeding or a ruptured ectopic pregnancy. It is unrelated to hypocalcemia.

B. Chvostek's sign: Chvostek's sign is a spasm or twitching of the facial muscles when the facial nerve is tapped, which is a classic sign of hypocalcemia due to low calcium levels affecting neuromuscular function.

C. Brudzinski's sign: Brudzinski's sign involves involuntary flexion of the knees and hips when the neck is flexed, indicative of meningitis. It is unrelated to hypocalcemia.

D. Kernig's sign: Kernig's sign involves resistance to leg extension when the hip is flexed and is indicative of meningitis. It is not associated with hypocalcemia.

A. The nurse applies a tourniquet to assess a vein. B. The nurse dons gloves before starting the IV. C. The nurse blows on the area cleansed with alcohol to dry it quickly D. The nurse cleans the area with an alcohol pad

Correct Answer is C

Explanation

A. The nurse applies a tourniquet to assess a vein: Applying a tourniquet is standard practice and does not increase infection risk if proper technique is used.

B. The nurse dons gloves before starting the IV: Wearing gloves minimizes the risk of infection for both the patient and the nurse.

C. The nurse blows on the area cleansed with alcohol to dry it quickly: Blowing on the site introduces bacteria from the nurse's breath to the cleansed area, increasing the risk of infection.

D. The nurse cleans the area with an alcohol pad: Cleaning the site with alcohol reduces the risk of infection and is standard practice.

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An older adult nursing home resident who has always been alert and oriented is now showing signs of dehydration and has become confused. Which electrolyte imbalance is most likely involved?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

Correct Answer is B

Explanation

The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection?

Correct Answer is C

Explanation

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