The nurse is assisting in the care of an adolescent athlete in the emergency department.
Blood pressure
Heart rate
Level of consciousness
BUN level
Sodium level
Correct Answer : C,E
A. Blood pressure
124/72 mm Hg is normal.
B. Heart rate
64/min is normal.
C. Level of consciousness
Disorientation and hallucinations ("looking for the cat") suggest altered mental status, possibly from hypernatremia or hyperosmolality.
D. BUN level
14 mg/dL is within normal range.
E. Sodium level
Sodium of 150 mEq/L is elevated. Hypernatremia can cause neurological changes and must be corrected cautiously.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Examine your testicles after a warm shower.":
Warmth relaxes the scrotal sac, making it easier to palpate the testicles and detect abnormalities such as lumps or swelling.
B. "Palpate both testicles firmly with your fingertips.":
Testicles should be palpated gently, not firmly, to avoid discomfort and ensure accurate detection of changes.
C. "Apply a cool compress to the scrotum prior to examination.":
Cold causes scrotal contraction, making the exam more difficult.
D. "Perform the self-examination every 3 months.":
The recommended frequency is monthly, not every 3 months.
Correct Answer is D
Explanation
A. Increased hemoglobin:
Clients with nephrotic syndrome may have anemia due to loss of erythropoietin or nutritional deficiencies, not increased hemoglobin.
B. Hyperalbuminemia:
Nephrotic syndrome is characterized by hypoalbuminemia due to massive urinary protein loss.
C. Hypolipidemia:
Clients often develop hyperlipidemia as the liver tries to compensate for protein loss by increasing lipoprotein production.
D. Proteinuria:
Massive proteinuria is the hallmark of nephrotic syndrome, often exceeding 3.5 g/day.
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