A 65-year-old female presents with confusion, headache, and muscle weakness. Her sodium level is 120 mEq/L. Which of the following interventions is most appropriate based on her condition?

Administer hypertonic saline and restrict water intake

Start fluid restriction and administer a loop diuretic

Administer isotonic saline and encourage oral fluid intake

Increase oral sodium intake and administer an antiemetic

Answer and Explanation

The Correct Answer is A

A. Administering hypertonic saline (3% NaCl) is appropriate for treating severe hyponatremia, as it helps to raise sodium levels safely. Restricting water intake is also necessary to prevent further dilution of sodium.
B. Fluid restriction with a loop diuretic may not be effective in this scenario and can worsen the hyponatremia by causing further fluid loss without addressing the sodium levels.
C. Isotonic saline is not indicated for correcting severe hyponatremia, and encouraging oral fluid intake could exacerbate the condition.
D. Increasing oral sodium intake is not sufficient for immediate correction of severe hyponatremia and does not address the acute nature of the client’s symptoms.

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Correct Answer is C

Explanation

A. Anuria, or the absence of urine output, indicates significant renal impairment and is a later sign of shock.
B. Hypotension is a classic sign of shock but occurs after compensatory mechanisms have failed.
C. An increased respiratory rate is often one of the earliest indicators of shock, as the body attempts to compensate for reduced oxygenation and tissue perfusion by increasing respiratory effort.
D. A decreased level of consciousness can occur with prolonged shock but typically presents after other compensatory mechanisms have been overwhelmed.

A. IV antibiotics B. Urinalysis C. Chest x-ray D. Chest tube placement E. Admit to inpatient F. Airborne precautions G. Draw an STI lab panel H. Complete blood count

Correct Answer is ["A","C","E","H"]

Explanation

The nurse anticipates the following orders from the provider based on the suspected diagnosis:

A. IV antibiotics: To treat the suspected infection.
C. Chest x-ray: To assess the lungs for signs of infection, such as pneumonia.
E. Admit to inpatient: The client's worsening condition and need for aggressive treatment warrant hospitalization.
H. Complete blood count: To assess the client's overall health status and identify any abnormalities, such as anemia or infection.

Rationale:

B. Urinalysis: While a urinalysis can be helpful in assessing for urinary tract infections, it is not a priority in this case.
D. Chest tube placement: This is not indicated unless the client develops a pleural effusion or pneumothorax.
F. Airborne precautions: This is not necessary for the client's current condition.
G. Draw an STI lab panel: While this may be relevant for the client's overall health, it is not a priority at this time, especially given the client's acute presentation.

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A 65-year-old female presents with confusion, headache, and muscle weakness. Her sodium level is 120 mEq/L. Which of the following interventions is most appropriate based on her condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["A","C","E","H"]

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