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: Stroke is not a cause of hyponatremia, but rather a possible complication of it. Hyponatremia is a condition where the sodium level in the blood is too low, which can affect the brain function and cause symptoms such as confusion, seizures, or coma. Stroke is a condition where the blood supply to a part of the brain is interrupted, which can cause brain damage and neurological deficits.
Choice B reason: Dehydration is not a cause of hyponatremia, but rather a cause of hypernatremia. Dehydration is a condition where the body loses more fluids than it takes in, which can affect the blood volume and the electrolyte balance. Dehydration can cause hypernatremia, which is a condition where the sodium level in the blood is too high, which can also affect the brain function and cause symptoms such as thirst, dry mouth, or lethargy.
Choice C reason: Increased secretion of aldosterone is not a cause of hyponatremia, but rather a cause of hypokalemia. Aldosterone is a hormone that regulates the sodium and potassium levels in the body by increasing the reabsorption of sodium and the excretion of potassium in the kidneys. Increased secretion of aldosterone can cause hypokalemia, which is a condition where the potassium level in the blood is too low, which can affect the muscle and nerve function and cause symptoms such as weakness, cramps, or arrhythmias.
Choice D reason: Congestive heart failure (CHF) is a cause of hyponatremia, as it is a condition where the heart is unable to pump enough blood to meet the body's needs. This can lead to fluid retention and edema, which can dilute the sodium level in the blood and cause hyponatremia. CHF can also stimulate the release of antidiuretic hormone (ADH), which increases the reabsorption of water in the kidneys and further lowers the sodium level in the blood.
Correct Answer is A
Explanation
Choice A reason: For an average adult, the total intake should be approximately equal to the total output every day¹². Therefore, if the patient's total output is 2200 mL, the total intake should also be around 2200 mL.
Choice B reason: 3000 mL is more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice C reason: 3800 mL is much more than the recommended daily fluid intake for an average adult, which is about 2500 mL³. If the patient's intake is higher than their output, they may develop fluid overload or edema.
Choice D reason: 2400 mL is slightly less than the recommended daily fluid intake for an average adult, which is about 2500 mL³. However, if the patient's intake is lower than their output, they may develop dehydration or electrolyte imbalance.
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