Which assessment finding is most indicative of hypernatremia?

Ascending muscle weakness

Muscle tetany and hyperreflexia

Poor turgor and dry mucous membranes

Bradycardia and hypotension

Answer and Explanation

The Correct Answer is C

A. Ascending muscle weakness is more characteristic of hypokalemia (low potassium levels) rather than hypernatremia.
B. Muscle tetany and hyperreflexia are typically seen in hypocalcemia (low calcium levels) or hypomagnesemia (low magnesium levels), not hypernatremia.
C. Hypernatremia (high sodium levels) commonly causes dehydration, which results in poor skin turgor and dry mucous membranes. This is a key clinical sign of hypernatremia.
D. Bradycardia and hypotension are more commonly associated with hypovolemia (low blood volume) or hypotension, but they are not specific to hypernatremia.

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Correct Answer is D

Explanation

A. Prepare the client for a CT scan is not the first priority in this case. A CT scan might be considered if there is suspicion of complications like a kidney stone or abscess, but it is not the first intervention.
B. Begin broad spectrum antibiotics could be considered if a urinary tract infection (UTI) is suspected, but obtaining urine samples for culture and urinalysis is necessary first to confirm the diagnosis and guide antibiotic therapy.
C. Insert a Foley catheter is not indicated unless the patient is unable to void or there is a need for continuous monitoring of urine output, but it is not the first step.
D. Obtain samples for urine culture and urinalysis is the first step to confirm the diagnosis of a urinary tract infection (UTI) and determine the appropriate treatment. This will help guide the selection of antibiotics.

A. Encouraging a low-sodium diet B. Padding the side rails of the bed C. Providing a quiet and calm environment D. Having the client use the call light when toileting is needed

Correct Answer is A

Explanation

A. Encouraging a low-sodium diet is inappropriate for a client with hyponatremia. Hyponatremia is a condition of low sodium levels in the blood, and the priority in managing this condition is to restore normal sodium levels, not to restrict sodium.
B. Padding the side rails of the bed is appropriate to protect the client from injury, especially if the client is at risk for seizures due to the electrolyte imbalance.
C. Providing a quiet and calm environment is beneficial for a client with hyponatremia, as it can help reduce the risk of seizures or agitation associated with the condition.
D. Having the client use the call light when toileting is needed is a standard precaution to ensure the client’s safety, especially if they are at risk of falls or confusion due to the electrolyte imbalance.

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Which assessment finding is most indicative of hypernatremia?

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Naxlex Comprehensive Predictor Exams

A client presents to the emergency department with complaints of urinary frequency, dysuria, and fever. Which of the following orders should the nurse carry out first?

Correct Answer is D

Explanation

Which of the following actions is inappropriate when implementing precautions in a client with hyponatremia?

Correct Answer is A

Explanation

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