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 ["A","C","E"]
Explanation
A. A client who has stage IV breast cancer and is expected to live 3 months:
This client is eligible for hospice care because they have a terminal illness (stage IV breast cancer) with a prognosis of less than six months to live if the disease follows its typical course. Hospice care focuses on comfort and quality of life in the final months of life.
B. A client who has a diagnosis of COPD and requires supplemental oxygen:
This client is not automatically eligible for hospice care based solely on a COPD diagnosis and the need for supplemental oxygen. Eligibility for hospice would require a prognosis of six months or less to live if the disease follows its usual course. More specific criteria, such as frequent hospitalizations or a significant decline in functional status, would need to be met.
C. A client who has end-stage kidney disease and has stopped dialysis:
This client is eligible for hospice care because stopping dialysis typically indicates that the client has a limited life expectancy, usually measured in weeks to months. Hospice care can help manage symptoms and provide support for end-of-life care.
D. A client who has type 1 diabetes mellitus and is on an insulin pump:
This client is not eligible for hospice care based solely on the presence of type 1 diabetes mellitus and the use of an insulin pump. Hospice care eligibility is generally for clients with a terminal diagnosis and a life expectancy of six months or less if the disease follows its usual course.
E. A client who has terminal lung cancer and has discontinued all treatment:
This client is eligible for hospice care because they have a terminal illness (lung cancer) and have chosen to discontinue curative treatment. Hospice care focuses on palliative treatment to improve the quality of life and manage symptoms during the end-of-life stage.
Correct Answer is A
Explanation
A) Cheyne-Stokes respirations:
Cheyne-Stokes respirations are characterized by a cycle of gradually increasing and then decreasing respirations followed by a period of apnea. This pattern repeats in a regular cycle. It is commonly observed in clients with conditions affecting the central nervous system, such as traumatic brain injury, stroke, or brain tumors. Cheyne-Stokes respirations can also occur during the dying process. The alternating periods of hyperventilation and apnea result from fluctuations in oxygen and carbon dioxide levels in the blood.
B) Kussmaul respirations:
Kussmaul respirations are deep, rapid, and labored breathing patterns often observed in clients with metabolic acidosis, particularly diabetic ketoacidosis. Unlike Cheyne-Stokes respirations, Kussmaul respirations do not involve periods of apnea.
C) Apneustic respirations:
Apneustic respirations are characterized by prolonged inspiratory gasps followed by insufficient expiration. This irregular breathing pattern typically indicates damage to the pons, a part of the brainstem involved in regulating breathing. Apneustic respirations are different from the pattern described in the scenario.
D) Stridor:
Stridor is a high-pitched, noisy respiratory sound heard on inspiration that indicates upper airway obstruction, such as from swelling, foreign body aspiration, or tumors. It is not associated with the alternating pattern of hyperventilation and apnea described in Cheyne-Stokes respirations.
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