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. Obstructive shock occurs when blood flow is physically obstructed, such as in cases of pulmonary embolism or cardiac tamponade, which is not indicated here as the cause is blood loss.
B. Septic shock is related to infection and systemic inflammatory response, not directly caused by blood loss.
C. Hypovolemic shock is caused by a significant loss of blood volume, leading to decreased blood pressure, which directly relates to the client losing 800 mL of blood during surgery. This condition results in inadequate perfusion and oxygen delivery to tissues.
D. Neurogenic shock results from spinal cord injuries leading to vasodilation and bradycardia, which is not applicable to this scenario.

A. Where did the assault occur? B. Do you give us permission to call the police? C. Who was the individual who assaulted you? D. What day and time did the assault take place?

Correct Answer is C

Explanation

A. While knowing the location of the assault may be relevant for police reports, it does not directly pertain to the client’s health and potential exposure to HIV.
B. Permission to contact the police is important for legal reasons, but the priority is to address the client's health needs first.
C. Identifying the individual who assaulted the client is critical for assessing the risk of HIV exposure and determining the need for post-exposure prophylaxis (PEP). This question directly impacts the client’s immediate health care.
D. Understanding the day and time of the assault is useful for legal documentation but is less critical than assessing potential exposure to HIV.

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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 C

Explanation

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