The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?
Urine output of 32 mL/hour.
Confusion and disorientation.
Blood pressure of 106/82.
2+ pedal edema bilaterally.
The Correct Answer is B
A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. Intact motor function is not a sign of compartment syndrome. Motor deficits, rather than intact function, would raise concern for this condition.
B. A capillary refill time of 5 seconds is prolonged and indicates impaired circulation, which is a sign of compartment syndrome.
C. A bounding pulse is not consistent with compartment syndrome. Pulses may initially remain normal but can diminish as the condition progresses.
D. Pallor to the lower extremity suggests compromised blood flow, which is a hallmark of compartment syndrome.
E. Numbness and tingling (paresthesia) indicate nerve compression, a common symptom of compartment syndrome.
Correct Answer is A
Explanation
A. A potassium level of 3.3 mEq/L indicates hypokalemia, which can lead to cardiac dysrhythmias due to the role of potassium in maintaining normal cardiac conduction and muscle contraction. Monitoring the client’s heart rhythm is crucial.
B. Neurogenic shock is not a complication of hypokalemia. It is typically caused by spinal cord injury or central nervous system damage, not electrolyte imbalances.
C. Hypoglycemia is not directly associated with hypokalemia or furosemide use. Furosemide primarily affects fluid and electrolyte balance, not glucose regulation.
D. While severe hypokalemia can cause neuromuscular issues, seizures are more commonly associated with conditions like hyponatremia or hypocalcemia, not hypokalemia.
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