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 C

Explanation

Choice A reason: Hyperchloremia, elevated chloride levels, is associated with metabolic acidosis or dehydration, not neuromuscular symptoms like wrist flexion. Chloride imbalances affect acid-base balance, not calcium-dependent muscle contractions. The inward wrist flexion suggests a neuromuscular excitability issue, which is more characteristic of low calcium levels than chloride abnormalities.

Choice B reason: Hypercalcemia, high calcium levels, causes muscle weakness, lethargy, and reduced reflexes, not increased neuromuscular excitability like wrist flexion. Calcium excess stabilizes nerve membranes, reducing spasms. The symptom described aligns with hypocalcemia, where low calcium increases nerve excitability, leading to tetany or abnormal muscle contractions.

Choice C reason: Hypocalcemia, low calcium levels, increases neuromuscular excitability due to decreased stabilization of nerve membranes. This can cause tetany, characterized by involuntary muscle contractions, such as wrist flexion (carpopedal spasm). The symptom is a classic sign of hypocalcemia, often seen in conditions like hypoparathyroidism or vitamin D deficiency.

Choice D reason: Hypomagnesemia, low magnesium, can cause neuromuscular symptoms like tremors or seizures but is less commonly associated with specific signs like wrist flexion. Magnesium affects muscle relaxation, and its deficiency typically causes generalized excitability. Hypocalcemia is more directly linked to tetany and carpopedal spasms, as seen in the client.

A. To obtain homeostasis B. To prevent infection C. To promote mobility D. To enhance nutrition

Correct Answer is A

Explanation

Choice A reason: Homeostasis is the body’s ability to maintain stable internal conditions, including fluid and electrolyte balance. Imbalances, like hypokalemia or hypernatremia, disrupt cellular function, potentially causing arrhythmias or neurological issues. Restoring homeostasis is the priority, as it addresses the root cause, ensuring proper organ function and preventing complications.

Choice B reason: Preventing infection is important but not the priority in fluid and electrolyte imbalances. Infections may occur secondary to other conditions, but the primary concern is correcting imbalances that affect cellular and organ function. Homeostasis must be achieved first to stabilize the client’s physiological state before addressing infection risks.

Choice C reason: Promoting mobility is relevant for overall health but not the priority in fluid and electrolyte imbalances. Imbalances can cause muscle weakness or arrhythmias, but restoring electrolyte levels takes precedence to ensure safe mobility. Without homeostasis, mobility efforts may be unsafe or ineffective due to physiological instability.

Choice D reason: Enhancing nutrition supports overall recovery but is secondary to correcting fluid and electrolyte imbalances. Nutritional deficiencies may contribute to imbalances, but the immediate goal is restoring homeostasis to prevent acute complications like cardiac or neurological dysfunction. Nutrition can be addressed once the client is stabilized.

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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

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 what condition?

Correct Answer is C

Explanation

A nurse is caring for a client who has a fluid and electrolyte imbalance. The nurse knows that the priority goal of taking care of this client is?

Correct Answer is A

Explanation

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