A nurse is assessing a client who has a decreased potassium level. Which of the following findings should the nurse expect?
Muscle weakness
Hyperreflexia
Chvostek's sign
Seizures
The Correct Answer is A
A. Muscle weakness: Potassium is essential for normal neuromuscular function, and a low serum potassium level disrupts muscle cell excitability and contractility. As a result, clients may present with generalized weakness, particularly in the lower extremities, and may have difficulty with mobility or respiration if the weakness progresses.
B. Hyperreflexia: Hyperreflexia is more commonly associated with elevated calcium or magnesium imbalances rather than decreased potassium. Hypokalemia typically causes reduced neuromuscular excitability, which would result in diminished or absent reflexes rather than increased reflex activity. Therefore, hyperreflexia is not an expected finding in a client with low potassium.
C. Chvostek's sign: Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It is elicited by tapping the facial nerve, resulting in twitching of the facial muscles. This sign indicates increased neuromuscular excitability due to low calcium levels, which is unrelated to potassium regulation. It is not expected in cases of decreased potassium.
D. Seizures: Seizures are more commonly linked with abnormalities in sodium or calcium levels, particularly hyponatremia or severe hypocalcemia. While severe hypokalemia can lead to cardiac arrhythmias and muscle paralysis, it is not typically associated with seizures. Therefore, seizures are not a standard finding in clients with hypokalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. 1/2 cup instant mashed potatoes: Instant mashed potatoes provide only a small amount of calcium, typically around 10–20 mg per serving. While they may be fortified with some nutrients, they are not considered a significant source of calcium and should not be relied on as an alternative to dairy for individuals with calcium needs.
B. 1/2 cup chopped tomatoes: Chopped tomatoes are very low in calcium, offering roughly 10 mg per 1/2 cup serving. Although tomatoes contain beneficial vitamins like vitamin C and antioxidants such as lycopene, they do not contribute meaningfully to daily calcium intake and are not suitable substitutes for calcium-rich foods.
C. 1/4 cup quinoa: Quinoa provides a modest amount of calcium—approximately 20–30 mg per 1/4 cup cooked. While it is a good plant-based protein and contains other minerals like magnesium and iron, its calcium content is not high enough to be considered a top alternative for those avoiding dairy.
D. 1/2 cup almonds: Almonds contain the highest amount of calcium among the listed options, with about 185–200 mg per 1/2 cup serving. They are an excellent non-dairy source of calcium, especially useful for clients with lactose intolerance or dairy allergies. In addition to calcium, almonds provide healthy fats, fiber, and magnesium, making them a nutritious alternative.
Correct Answer is B
Explanation
A. Encourage the client to eat even if nauseated: Encouraging a client to eat despite nausea can worsen the sensation and potentially lead to vomiting. Nausea due to equilibrium imbalance, is more effectively managed by addressing the underlying cause and tailor meals to reduce nausea triggers. Forcing food intake may increase discomfort and reduce overall nutritional compliance.
B. Provide low-fat carbohydrates with meals: Low-fat carbohydrates, such as crackers, toast, or rice, are easier to digest and less likely to trigger nausea compared to high-fat or heavy meals. These types of foods can help settle the stomach and maintain energy levels without worsening nausea.
C. Limit fluid intake between meals: Limiting fluid intake between meals is not typically recommended for nausea caused by equilibrium imbalance. Adequate hydration is essential, and fluids can sometimes help reduce nausea if consumed in small, frequent sips. Restricting fluids without clinical indication could contribute to dehydration and worsen symptoms.
D. Serve hot foods at mealtime: Hot foods tend to have stronger smells, which can trigger or worsen nausea in sensitive individuals. Cool or room-temperature foods are better tolerated by clients experiencing nausea, especially when the nausea is related to vestibular issues. Reducing olfactory stimulation helps in managing nausea more effectively.
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