Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 45 mq, calcium 45 mg/dL?
Light-headedness when standing up
Weak quadriceps muscles
Decreased deep tendon reflexes
Tingling of extremities
The Correct Answer is D
A. Light-headedness when standing up:
Elevated potassium levels (hyperkalemia) can lead to muscle weakness or paralysis, cardiac dysrhythmias, and even cardiac arrest. Light-headedness when standing up is more commonly associated with orthostatic hypotension or volume depletion rather than electrolyte imbalances like hyperkalemia.
B. Weak quadriceps muscles:
Weakness in the quadriceps muscles is not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can cause muscle weakness, but it is not specific to the quadriceps.
C. Decreased deep tendon reflexes:
Decreased deep tendon reflexes are not typically associated with the electrolyte imbalances presented in the scenario. Hyperkalemia can lead to hyperreflexia or absent reflexes, but it is not specific to decreased deep tendon reflexes.
D. Tingling of extremities:
This is the correct answer. Hypocalcemia, indicated by the low calcium level in the scenario, can manifest with symptoms such as tingling or numbness of the extremities, muscle cramps, and tetany. Calcium plays a crucial role in nerve transmission, and low levels can lead to sensory disturbances like tingling in the extremities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Helping the client select a low-salt diet:
This option is not directly related to addressing tenacious bronchial secretions in COPD. While a low-salt diet may be beneficial for managing conditions like hypertension or heart failure, it does not directly influence the viscosity of bronchial secretions.
B. Administering oxygen via nasal cannula at 2 L/min:
Oxygen therapy is important for clients with COPD, especially during exacerbations or periods of hypoxemia. However, in this scenario, the client's primary concern is tenacious bronchial secretions, and oxygen therapy alone may not effectively address this issue.
C. Encouraging the client to drink 2 to 3 L of water daily:
This is the correct answer. Increasing fluid intake helps to hydrate the mucous membranes and thin bronchial secretions, making them easier to expectorate. Adequate hydration is essential for optimizing the clearance of secretions in clients with COPD.
D. Maintaining a semi-Fowler's position as often as possible:
While maintaining a semi-Fowler's position can improve respiratory mechanics and reduce dyspnea in clients with COPD, it does not directly address the issue of tenacious bronchial secretions. This position primarily helps in optimizing lung expansion and facilitating easier breathing.
Correct Answer is A
Explanation
A. Severity
In the PQRST mnemonic for pain assessment, "S" stands for Severity. When the nurse asks the client to rate the pain on a scale of 0 to 10, they are assessing the severity of the pain. This helps the nurse understand the intensity of the client's pain experience and provides a baseline for evaluating the effectiveness of pain management interventions.
B. Precipitating cause
This component relates to factors that exacerbate or alleviate the pain and is represented by the "P" in the PQRST mnemonic. Asking about activities or events that preceded the onset of pain helps identify potential triggers or causes.
C. Region
The "R" in PQRST represents Region, referring to the specific location or area where the client experiences pain. Assessing the region helps localize the source of pain and guide further diagnostic evaluations or interventions.
D. Quality
Quality, represented by the "Q" in PQRST, refers to the characteristics or nature of the pain, such as sharp, dull, throbbing, or burning. Understanding the quality of pain provides additional information about its underlying cause and can aid in selecting appropriate treatment strategies.
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