The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?
"Do you drink milk or eat dairy products at each meal?"
"How much water and ice chips do you have each day?"
"What amount of your daily meals contains fresh vegetables?"
"How frequently do you eat processed or canned foods?"
The Correct Answer is B
Choice A reason: Asking about the consumption of milk or dairy products is not directly related to the client's serum sodium level. Dairy intake does not typically cause significant changes in sodium levels. Therefore, this question would not help in identifying the cause of the hyponatremia.
Choice B reason: This question is most relevant because excessive water or ice chip intake can lead to dilutional hyponatremia. Ingestion of large amounts of water can dilute the sodium concentration in the blood, resulting in a low serum sodium level. Identifying excessive fluid intake is critical in determining if this is the cause of the client's hyponatremia.
Choice C reason: Inquiring about the number of fresh vegetables in the client's diet is more related to overall nutrition rather than directly linked to sodium levels. While vegetables can be part of a healthy diet, this question would not specifically address the cause of a low serum sodium level.
Choice D reason: The frequency of consuming processed or canned foods, which are typically high in sodium, would generally be expected to increase serum sodium levels rather than decrease them. Therefore, this question does not directly address the issue of a low sodium level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A bounding peripheral pulse indicates increased arterial circulation and is not a sign of compromised peripheral arterial circulation. In cases of arterial insufficiency, pulses may actually be diminished or absent.
Choice B reason: Uneven hair distribution is a classic sign of compromised peripheral arterial circulation. Poor blood flow to the extremities can lead to decreased hair growth, causing patchy or uneven hair distribution. This symptom is often seen in clients with peripheral arterial disease.
Choice C reason: Lower leg enema is more commonly associated with venous insufficiency rather than arterial insufficiency. Edem results from fluid accumulation due to poor venous return rather than issues with arterial circulation.
Choice D reason: Bronze pigmentation is often related to chronic venous insufficiency and hemosiderin deposition in the skin. It is not typically a sign of compromised arterial circulation. Arterial issues are more likely to cause pallor or cyanosis in the affected extremity.
Correct Answer is D
Explanation
Choice A reason: Calling the postanesthetic care unit (PACU) nurse to prepare for prolonged ventilatory support is important in certain situations. However, in this case, the client's immediate concern is the extremely high temperature, which needs to be addressed urgently.
Choice B reason: Determining if prescribed antibiotics were administered preoperatively is a standard procedure, but it is not relevant to the acute situation of muscle rigidity and extremely high temperature caused by succinylcholine. The nurse should focus on immediate cooling measures.
Choice C reason: Holding a prescription for dantrolene until the fever is reduced is not appropriate. Dantrolene is actually used to treat malignant hyperthermia, which is characterized by muscle rigidity and a high temperature. It should be administered immediately in such cases.
Choice D reason: Preparing ice packs for placement in the client's axillary area is a direct and immediate action to help reduce the client's extremely high temperature. Cooling measures are crucial to manage hyperthermia and prevent further complications.
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