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A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect?

A.

Muscle weakness

B.

Oliguria

C.

Hypoactive bowel sounds

D.

Hypertension

Answer and Explanation

The Correct Answer is A

A. Muscle weakness: Hyperkalemia disrupts normal muscle cell function by affecting membrane excitability, leading to symptoms like muscle weakness or even paralysis in severe cases. It is one of the hallmark signs of elevated potassium levels.
B. Oliguria: While hyperkalemia may be associated with renal impairment, oliguria is not a direct manifestation of high potassium but rather a possible contributing factor. It is not specific to hyperkalemia itself.
C. Hypoactive bowel sounds: Increased potassium levels typically cause hyperactivity of the gastrointestinal tract, leading to hyperactive bowel sounds and cramping, not reduced or hypoactive activity.
D. Hypertension: Hyperkalemia more commonly results in hypotension due to its effects on cardiac conduction and vasculature. Hypertension is not a typical manifestation of elevated serum potassium.
 


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Related Questions

Correct Answer is C

Explanation

A. Instruct the client on the use of esophageal speech: Esophageal speech is a technique used after laryngectomy and is not relevant for managing xerostomia caused by radiation therapy to the mandible.
B. Suggest rinsing his mouth with an alcohol-based mouthwash: Alcohol-based mouthwashes can further dry and irritate the oral mucosa, worsening xerostomia symptoms, so this is not appropriate.
C. Provide humidification of the room air: Increasing humidity helps keep the mucous membranes moist, relieving dry mouth symptoms and providing comfort for clients experiencing xerostomia after radiation therapy.
D. Offer the client saltine crackers between meals: Dry, salty foods like saltine crackers can exacerbate dry mouth and discomfort, so this recommendation is not appropriate for xerostomia management.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A,B,C"}}

Explanation

  • Urticaria: Urticaria (hives) is a hallmark sign of an allergic reaction, particularly latex allergy, and typically appears quickly following exposure to allergens. It is not seen in malignant hyperthermia or hypovolemic shock.
  • Wheezing: Wheezing can occur in latex allergy due to bronchospasm or airway edema. While respiratory compromise may happen in malignant hyperthermia, it is typically due to muscle breakdown and CO2 retention, not bronchospasm. Wheezing is not expected in hypovolemic shock.
  • Muscle rigidity: Generalized rigidity, especially of the jaw (masseter spasm), is a key early sign of malignant hyperthermia, a life-threatening reaction to certain anesthetics. It is not a symptom of latex allergy or hypovolemic shock.
  • Hypercapnia: An elevated PaCO₂ is an early, sensitive marker of malignant hyperthermia, resulting from increased CO₂ production due to sustained muscle contraction. This does not occur in latex allergy or hypovolemic shock.
  • Tachycardia: Elevated heart rate can be seen in all three conditions: in malignant hyperthermia due to increased metabolic demand, in latex allergy due to anaphylactic reaction, and in hypovolemic shock as a compensatory response to fluid loss.

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