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A 73-year-old hospitalized client demonstrates the following symptoms: dry mucous membranes, decreased urine output, confusion, a serum sodium of 158 mEq/L, and a serum potassium of 4.8 mEq/L. The nurse recognizes that these symptoms are indicative of:
Hypernatremia
Hyperkalemia
Hyponatremia
Hypokalemia
The Correct Answer is:
A. Hypernatremia
Detailed Explanation:
Hypernatremia occurs when serum sodium levels exceed 145 mEq/L, leading to cellular dehydration. Common signs include dry mucous membranes, decreased urine output, confusion, thirst, and neurological changes, particularly in older adults who may have impaired thirst mechanisms. The elevated sodium value of 158 mEq/L confirms the diagnosis. Potassium levels are within normal range, ruling out potassium imbalances. Treatment focuses on gradual fluid replacement with hypotonic solutions and close monitoring to prevent cerebral edema.
A report on a group of clients is being given to a nurse. The nurse should see which of the following clients first, according to the ABCDE priority framework?
A client who is scheduled for discharge and has become febrile this morning.
A client who has early dementia and awoke confused to their location this morning.
A client who has pneumonia and has developed wheezing.
A client who is postoperative and has a urine output of 50 mL for the past 4 hours.
The Correct Answer is:
C. A client who has pneumonia and has developed wheezing.
Detailed Explanation:
The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) framework prioritizes airway and breathing issues first. Wheezing in a client with pneumonia indicates narrowing of the airways and potential respiratory compromise, which can rapidly lead to hypoxia or respiratory failure. This client requires immediate assessment and possible interventions such as oxygen therapy, bronchodilators, or airway support. The other clients are stable or have non-life-threatening conditions that can be safely addressed afterward.
A patient is hypercalcemic. As part of his treatment, the nurse would expect to:
Hydrate the patient.
Administer vitamin D.
Increase intake of dairy products.
Administer IV sodium bicarbonate.
The Correct Answer is:
A. Hydrate the patient.
Detailed Explanation:
Hydration is the first-line treatment for hypercalcemia because it helps dilute calcium levels in the blood and promotes renal excretion of excess calcium through increased urine output. Intravenous normal saline is typically administered to restore fluid balance and prevent kidney stones. Vitamin D and dairy products would worsen hypercalcemia by raising calcium levels further, while sodium bicarbonate is not indicated for calcium regulation. Maintaining hydration helps protect kidney function and safely lower calcium levels.
A client reads the nutritional chart and follows it accurately. The nurse also notes that the client understands the need for a balanced diet and its relationship with a quick recovery. In which domain is the client demonstrating successful learning?
Affective
Psychomotor
Interpersonal
Cognitive
The Correct Answer is:
D. Cognitive
Detailed Explanation:
The cognitive domain involves acquiring and demonstrating knowledge, comprehension, and critical thinking. By reading the nutritional chart and understanding how a balanced diet promotes faster recovery, the client is applying learned information to health behaviors. This shows comprehension and the ability to make informed decisions. The affective domain relates to emotions and attitudes, while the psychomotor domain involves physical skills, and the interpersonal domain focuses on social interactions rather than knowledge-based understanding.
During shift report, the nurse learns that a patient has a positive Chvostek's sign. The nurse expects lab tests to reveal:
Serum calcium < 8.9 mg/dL
Sodium < 135 mEq/L
Serum calcium > 10.5 mg/dL
Sodium > 145 mEq/L
The Correct Answer is:
A. Serum calcium < 8.9 mg/dL.
Detailed Explanation:
A positive Chvostek’s sign indicates neuromuscular irritability, which is commonly caused by hypocalcemia—a serum calcium level below 8.9 mg/dL. This condition increases excitability of nerves and muscles, producing twitching of facial muscles when the facial nerve is tapped. Hypocalcemia may result from hypoparathyroidism, vitamin D deficiency, or acute pancreatitis. In contrast, hypercalcemia (>10.5 mg/dL) suppresses neuromuscular activity, and sodium imbalances are unrelated to this specific finding.
As the nurse assesses a client's blood pressure, the patient's wrist severely flexes inward. The nurse questions the client's response because this finding may indicate:
Hypomagnesemia
Hypophosphatemia
Hyperchloremia
Hypercalcemia
The Correct Answer is:
A. Hypomagnesemia
Detailed Explanation:
Severe wrist flexion during blood pressure assessment is known as a positive Trousseau’s sign, which indicates neuromuscular irritability caused by low magnesium or calcium levels. Hypomagnesemia increases nerve excitability and muscle contraction, leading to carpopedal spasms when blood flow is temporarily occluded. This electrolyte imbalance can result from malnutrition, alcoholism, or diuretic use. The nurse should promptly report this finding, assess for concurrent hypocalcemia, and anticipate intravenous magnesium replacement.
A nurse is preparing a patient for discharge home and is teaching them how to change their wound dressing. What is the best way to evaluate the effectiveness of the teaching session?
Have the patient demonstrate removing the dressing and applying a new one.
Give the patient a multiple-choice quiz on the content taught.
Ask the patient to repeat all the steps of the procedure and rationale for each.
Ask the patient whether or not the instructions were clear.
The Correct Answer is:
A. Have the patient demonstrate removing the dressing and applying a new one.
Detailed Explanation:
The most effective way to evaluate teaching, especially for psychomotor skills like wound care, is through return demonstration. By having the patient perform the dressing change, the nurse can directly observe their technique, identify any errors, and provide immediate correction. This ensures that the patient can safely perform the task at home and helps reinforce learning through practice.
The nurse in a community health clinic is assessing a 10-year-old client accompanied by his parents. They are discussing their concerns about the child's somnambulism. Which of the following would be the highest priority nursing diagnosis for this patient?
Risk for caregiver role strain
Risk for injury
Risk for delayed development
Sleep deprivation
The Correct Answer is:
B. Risk for injury
Detailed Explanation:
Somnambulism, or sleepwalking, places the child at significant risk for injury due to movement during sleep without awareness of surroundings. Safety is always the nurse’s highest priority. The child may fall, walk into objects, or attempt unsafe activities such as leaving the house. Interventions should include ensuring a safe environment, locking doors and windows, and educating parents on supervision and injury prevention. Addressing safety first helps prevent harm before addressing other related concerns.
A 14-year-old female student is brought to the clinic by her mother who says that the client has been trying to lose weight. The client complains of feeling tired and weak and admits that she has been using laxatives to help lose weight. The nurse recognizes that the client is probably experiencing what electrolyte imbalance?
Hypocalcemia
Hyperkalemia
Hypokalemia
Hypernatremia
The Correct Answer is:
C. Hypokalemia
Detailed Explanation:
Laxative abuse leads to excessive loss of water and electrolytes, particularly potassium, through the gastrointestinal tract. Low serum potassium (hypokalemia) can cause muscle weakness, fatigue, cardiac dysrhythmias, and general lethargy. In this case, the client’s symptoms of weakness and fatigue are classic indicators of hypokalemia. Chronic laxative use is common in eating disorders like bulimia or anorexia nervosa, and monitoring electrolyte levels is essential to prevent serious complications such as cardiac arrest.
A nurse is working with a client in the hospital setting and prioritizing addressing their concerns. Using Maslow's hierarchy of needs, place the concerns in order of priority to address.
1.The client missed breakfast due to a procedure and is requesting a tray.
2.The client is concerned about scarring of the incision from the procedure.
3.The client's partner was in the waiting room during the procedure and would like to see them.
4.During the procedure, the client locked up his wallet and would like it returned.
1, 3, 4, 2
3, 1, 4, 2
1, 4, 3, 2
4, 1, 3, 2
The Correct Answer is:
A. 1, 3, 4, 2
Detailed Explanation:
Maslow prioritizes physiological needs first; hunger (missed breakfast) is the most basic requirement and must be addressed to restore energy and comfort. Next are love/belonging needs; facilitating a visit with the partner supports connection, reduces anxiety, and promotes healing. Safety and security follow; returning the locked wallet addresses personal security and control over belongings. Concerns about incision scarring reflect esteem/body image, which are important but come after physiological, safety, and belonging needs have been met.
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