The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hypernatremia. Which sign/symptom would the nurse expect to note in this client if hypernatremia is present?
Polyuria
Dry mucous membranes
Diarrhea
Intense thirst
Vomiting
The Correct Answer is B
Choice A reason: This is incorrect because polyuria is a sign of hyponatremia, not hypernatremia. Polyuria is the excessive production of urine, which can cause fluid loss and sodium dilution.
Choice B reason: This is correct because dry mucous membranes are a sign of hypernatremia. Dry mucous membranes are caused by dehydration, which can occur in hypernatremia due to fluid shifting from the intracellular to the extracellular space.
Choice C reason: This is incorrect because diarrhea is a sign of hyponatremia, not hypernatremia. Diarrhea is the frequent and watery passage of stool, which can cause fluid and electrolyte loss.
Choice D reason: This is incorrect because intense thirst is a sign of both hyponatremia and hypernatremia. Intense thirst is a result of the body's attempt to restore fluid balance and osmolarity.
Choice E reason: This is incorrect because vomiting is a sign of both hyponatremia and hypernatremia. Vomiting is a reflex action that expels the contents of the stomach, which can cause fluid and electrolyte loss or imbalance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Kidney function is not indicated by the PaCO2 level, but rather by the creatinine and blood urea nitrogen (BUN) levels. The kidneys are responsible for regulating the HCO3- level, which is the other component of the carbonic acid-bicarbonate buffer system.
Choice B reason: Bicarbonate buffers are not indicated by the PaCO2 level, but rather by the HCO3- level. Bicarbonate buffers are substances that can accept or donate hydrogen ions to maintain the pH of the blood. They are part of the carbonic acid-bicarbonate buffer system, which is the main buffer system in the body.
Choice C reason: Phosphate buffers are not indicated by the PaCO2 level, but rather by the PO4^3^- level. Phosphate buffers are substances that can accept or donate hydrogen ions to maintain the pH of the intracellular fluid and the urine. They are part of the phosphoric acid-phosphate buffer system, which is the second most important buffer system in the body.
Choice D reason: Lung ventilation is indicated by the PaCO2 level, which is the partial pressure of carbon dioxide in the blood. Lung ventilation is the process of moving air in and out of the lungs, which affects the amount of carbon dioxide exhaled. The lungs are responsible for regulating the PaCO2 level, which is the other component of the carbonic acid-bicarbonate buffer system.
Correct Answer is B
Explanation
Choice A reason: Panting with mouth open is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the risk of hyperventilation and respiratory alkalosis, which could worsen the anxiety and cause symptoms such as dizziness, tingling, and muscle spasms.
Choice B reason: Sitting up is an appropriate intervention for an anxious patient with a high respiratory rate. This could help the patient relax and breathe more deeply and slowly, which could reduce the anxiety and normalize the blood gas levels.
Choice C reason: Lying down is not an appropriate intervention for an anxious patient with a high respiratory rate. This could make the patient feel more claustrophobic and increase the anxiety and the respiratory rate.
Choice D reason: Breathing through a re-breather mask is not an appropriate intervention for an anxious patient with a high respiratory rate. This could increase the oxygen concentration in the blood, which could reduce the stimulus for breathing and cause respiratory depression.
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