Which action should be included in the teaching plan for a patient with hypernatremia?
Drink plenty of water whenever thirsty.
Review food labels for sodium content.
Monitor daily urine output volume.
Use salt tablets after strenuous exercise.
The Correct Answer is B
Drinking plenty of water whenever thirsty is not the most appropriate action for a patient with hypernatremia. While it's important to stay hydrated, excessive water intake can potentially worsen hypernatremia by diluting blood sodium levels further. This is because the body tries to balance sodium levels by either retaining water or excreting it through urine. In hypernatremia, the body is already short on water relative to sodium, so consuming too much water can exacerbate the imbalance.
Choice B rationale:
Reviewing food labels for sodium content is crucial for managing hypernatremia. It empowers patients to make informed choices and limit their sodium intake.
Sodium is a major contributor to hypernatremia, and reducing dietary sodium intake is a key strategy to lower blood sodium levels.
By carefully reading food labels and selecting low-sodium options, patients can effectively manage their sodium intake and promote a gradual return to normal sodium levels.
This approach addresses the root cause of hypernatremia and promotes long-term control of blood sodium levels.
Choice C rationale:
Monitoring daily urine output volume can be helpful in tracking fluid status, but it's not the primary action for managing hypernatremia.
While urine output can provide insights into fluid balance, it doesn't directly address the underlying issue of excessive sodium. Focusing on dietary sodium intake is a more direct and effective approach to correcting hypernatremia.
Choice D rationale:
Using salt tablets after strenuous exercise is not recommended for patients with hypernatremia.
Salt tablets are intended to replenish electrolytes lost through sweating, but they can worsen hypernatremia by further increasing sodium levels.
Patients with hypernatremia should focus on reducing sodium intake, not increasing it.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Chronic pain is a significant concern for this client, but it is not the immediate priority. Pain can be managed with medications and comfort measures, while aspiration can be life-threatening.
Tissue destruction by the tumor is likely contributing to the pain, but addressing the risk of aspiration takes precedence.
Uncontrolled pain can exacerbate anxiety and make it difficult to focus on other interventions, but ensuring airway safety is paramount.
Choice B rationale:
Anxiety and grieving are expected reactions to a diagnosis of esophageal cancer, and they should be addressed as part of the client's care plan. However, they are not the immediate priority in this case.
The progression of the disease is a significant stressor, but attending to the risk of aspiration is essential for the client's safety. Psychological distress can negatively impact coping and quality of life, but addressing physical needs takes precedence.
Choice D rationale:
Imbalanced nutrition is a concern for this client due to dysphagia and anorexia. However, it is not the immediate priority. Nutritional interventions can be implemented once the risk of aspiration is addressed.
Difficulty swallowing can lead to inadequate intake and malnutrition, but ensuring airway safety is the primary concern.
Anorexia can further contribute to nutritional deficits, but preventing aspiration is the most pressing issue.
Choice C is the priority nursing problem because:
The client's dysphagia puts them at immediate risk for aspiration, which can lead to pneumonia, respiratory failure, and even death.
Addressing the risk of aspiration is essential to ensure the client's safety and prevent life-threatening complications. It's crucial to implement interventions to minimize the risk of aspiration, such as:
Elevating the head of the bed during meals and for 30-60 minutes after eating Thickening liquids and pureeing foods
Encouraging small, frequent meals
Monitoring for signs of aspiration, such as coughing, choking, or difficulty breathing
Correct Answer is B
Explanation
Choice B rationale:
Isoniazid's Mechanism of Action:
It targets and inhibits the synthesis of mycolic acids, which are essential components of the cell wall of Mycobacterium tuberculosis, the bacteria that cause tuberculosis.
By disrupting cell wall formation, isoniazid prevents bacterial growth and multiplication, leading to the suppression and eventual eradication of the infection.
Clinical Manifestations of Active TB:
Persistent cough, often productive of sputum (phlegm), is a hallmark symptom of TB. The sputum may contain blood or have a rusty-colored appearance.
Other common symptoms include fever, night sweats, fatigue, weight loss, and chest pain. How Isoniazid Reduces Cough and Sputum:
As isoniazid effectively kills the TB bacteria, the inflammatory process within the lungs subsides.
This leads to a gradual decrease in the production of sputum, which is a direct result of the inflammatory response. Consequently, the frequency and severity of coughing episodes also diminish.
Monitoring Treatment Response:
Regular sputum smears and cultures are essential to assess the response to treatment.
A positive sputum smear indicates the presence of live TB bacteria, while a positive culture confirms their growth in the laboratory.
A gradual decrease in the number of bacteria seen on sputum smears, followed by negative cultures, signals a favorable response to treatment.
Timeframe for Improvement:
It's important to note that clinical improvement, including a reduction in cough and sputum, may not be immediately evident. It typically takes several weeks of consistent isoniazid therapy to achieve noticeable results.
Therefore, adherence to the prescribed treatment regimen is crucial for successful TB eradication. Addressing Other Choices:
Choice A: Decreased appetite and weight loss are often associated with active TB due to systemic inflammation and nutritional deficiencies. While isoniazid treatment may indirectly improve appetite and weight gain over time, these are not primary indicators of its effectiveness in suppressing the TB infection itself.
Choice C: Vertigo and tinnitus are potential side effects of isoniazid, but they do not reflect its efficacy in treating TB.
Choice D: A positive sputum smear and culture would indicate ongoing TB infection and a lack of response to treatment.
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