A 73-year-old hospitalized client demonstrates the following symptoms: dry mucous membranes, decreased urine output, confusion, a serum sodium of 153 mEq/L, and a serum condition difficult to measure. This is indicative of?

Sensible water loss

Major magnesium losses

Insensible water loss

Low potassium levels

Answer and Explanation

The Correct Answer is C

Choice A reason: Sensible water loss refers to measurable fluid loss, like urine or sweat. The client’s symptoms, including high serum sodium (153 mEq/L), suggest hypernatremia due to water loss, but sensible losses like urine are reduced (decreased urine output). Insensible losses better explain the unmeasurable fluid deficit in this scenario.

Choice B reason: Major magnesium losses cause hypomagnesemia, leading to tremors or arrhythmias, not typically confusion or hypernatremia. The client’s high sodium and dehydration symptoms point to water loss, not magnesium. Magnesium levels are not provided, and the symptoms align more with fluid imbalance than magnesium deficiency.

Choice C reason: Insensible water loss, from skin and respiration, is unmeasurable and can lead to hypernatremia (serum sodium 153 mEq/L) due to concentrated blood. Dry mucous membranes, decreased urine output, and confusion indicate dehydration from water loss, consistent with insensible losses in elderly patients with reduced thirst perception.

Choice D reason: Low potassium levels (hypokalemia) cause muscle weakness and arrhythmias, not hypernatremia or confusion. The client’s high sodium and dehydration symptoms point to water loss, not potassium imbalance. Potassium levels are not provided, but the clinical picture supports insensible water loss as the primary issue.

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Correct Answer is A

Explanation

Choice A reason: Rebound tenderness at McBurney’s point (right lower quadrant) indicates peritoneal irritation, a hallmark of appendicitis. The inflamed appendix causes localized pain, exacerbated by pressure release due to peritoneal inflammation. This specific finding is highly suggestive of appendicitis, distinguishing it from other abdominal conditions.

Choice B reason: Left lower quadrant pain is not typical for appendicitis, which usually presents in the right lower quadrant due to the appendix’s anatomical location. Left-sided pain may suggest conditions like diverticulitis or colitis, but it does not align with the localized inflammation characteristic of appendicitis.

Choice C reason: High-pitched bowel sounds suggest increased peristalsis, as in early obstruction, but are not specific to appendicitis. Appendicitis may reduce bowel sounds due to peritoneal irritation. Rebound tenderness is a more direct indicator, as it reflects the localized inflammation and irritation of appendicitis.

Choice D reason: A soft, non-tender abdomen is inconsistent with appendicitis, which causes localized pain and tenderness due to inflammation. A non-tender abdomen suggests a normal or alternative condition, not appendicitis, where peritoneal irritation typically produces tenderness, especially at McBurney’s point, upon palpation or rebound.

A. Advance the catheter to the bifurcation or “Y” level of the ports B. Instruct the patient to contract or squeeze his pelvic muscles C. Bathe the catheter after urine appears in the tube prior to inflating the balloon D. Advance the catheter 2–3 inches after urine appears in the tube prior to inflating the balloon

Correct Answer is D

Explanation

Choice A reason: Advancing to the bifurcation ensures the balloon is in the bladder but risks over-insertion, potentially damaging the urethra. Proper technique involves advancing 2–3 inches after urine flow to confirm bladder placement, ensuring the balloon inflates safely without obstructing the urethra or causing trauma.

Choice B reason: Instructing pelvic muscle contraction is irrelevant during catheterization, as it does not aid insertion or balloon placement. Pelvic exercises may help post-catheterization for continence but are not part of insertion protocol. The focus is on correct catheter positioning to avoid complications like bladder trauma.

Choice C reason: Bathing the catheter after urine appears is unnecessary and not standard practice. Catheter insertion requires sterile technique, and cleaning occurs before insertion. Post-urine cleaning risks contamination or delay in securing the catheter, potentially causing displacement or infection, making this an incorrect step.

Choice D reason: Advancing the catheter 2–3 inches after urine appears ensures the balloon is fully in the bladder before inflation, preventing urethral trauma or balloon rupture. This standard technique confirms proper placement, as urine flow indicates the catheter tip has reached the bladder, ensuring safe and effective catheterization.

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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 153 mEq/L, and a serum condition difficult to measure. This is indicative of?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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