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
Explanation
A) Socioeconomic:
Stress related to homelessness is categorized as a socioeconomic stressor. Socioeconomic stressors arise from economic or social factors such as poverty, unemployment, housing instability, or lack of access to resources. Homelessness is a significant socioeconomic stressor that can impact various aspects of a person's life, including physical health, mental well-being, and social relationships.
B) Adventitious:
Adventitious stressors refer to unexpected or traumatic events that are outside the individual's control, such as natural disasters, accidents, or crimes. While homelessness can result from various circumstances, it is not typically classified as an adventitious stressor.
C) Cultural:
Cultural stressors pertain to conflicts or challenges related to cultural identity, values, beliefs, or practices. While cultural factors may intersect with the experience of homelessness, the primary stressor in this scenario is socioeconomic rather than cultural.
D) Developmental:
Developmental stressors are related to life transitions or stages of development, such as adolescence, adulthood, or aging. While homelessness can certainly affect individuals at different life stages, the primary stressor in this scenario is the socioeconomic aspect of homelessness rather than a specific developmental stage.
Correct Answer is A
Explanation
A. "It sounds like you are exhausted."
This response demonstrates empathy and acknowledges the client's emotional state. The "E" in the NURSE mnemonic stands for "empathize," which involves recognizing and validating the client's feelings. By acknowledging that the client may be exhausted, the nurse shows understanding and empathy towards the client's experience of feeling overwhelmed.
B. "Tell me more about how you are feeling."
This response demonstrates active listening and encourages the client to express their emotions further. While important for therapeutic communication, it does not specifically address the client's feeling of being overwhelmed as directly as option A.
C. "You have so much to deal with. How can I be of help to you?"
This response demonstrates support and willingness to assist the client but does not directly address the client's reported feeling of being overwhelmed.
D. "It is impressive how you have managed to deal with the situation."
This response offers praise but does not directly address the client's reported feeling of being overwhelmed. It may also inadvertently minimize the client's feelings by focusing on their ability to cope rather than acknowledging their current emotional state.
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