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

Strong, bounding pulse

Positive Chvostek's sign

Hyperactive reflexes

Decreased bowel sounds

Answer and Explanation

The Correct Answer is D

A. Strong, bounding pulse: Hypokalemia causes weak, thready, or irregular pulses due to its effects on cardiac muscle excitability. A strong, bounding pulse is more characteristic of hypervolemia or other cardiovascular conditions.

B. Positive Chvostek's sign: A positive Chvostek’s sign is associated with hypocalcemia, not hypokalemia. It indicates neuromuscular excitability due to low calcium levels.

C. Hyperactive reflexes: Hypokalemia generally causes muscle weakness, fatigue, and diminished or hypoactive reflexes rather than hyperactive reflexes.

D. Decreased bowel sounds: Low potassium levels reduce smooth muscle excitability in the gastrointestinal tract, leading to decreased peristalsis and hypoactive bowel sounds, which is a common finding in hypokalemia.

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Correct Answer is A

Explanation

A. 65 mL: The total liquid intake includes 30 mL of water used to flush the NG tube before the medication, 5 mL of medication instilled, and 30 mL of water used to flush the tube afterward. Adding these together gives 65 mL, which accurately reflects all fluids administered.

B. 5 mL: Documenting only the medication omits the water used for flushing, underrepresenting the client’s total fluid intake.

C. 35 mL: This amount accounts only for the post-flush water and medication, it ignores the pre-flush water, resulting in an inaccurate intake record.

D. 60 mL: This underestimates the total intake by failing to include all three components correctly; precise documentation is essential for fluid balance monitoring.

A. Peer pressure B. Death of a family member C. Fear of medical test results D. Job transfer to another city

Correct Answer is C

Explanation

A. Peer pressure: Peer pressure is considered an external stressor because it originates from outside influences, such as social interactions and the expectations of others. It impacts behavior but is not generated internally.

B. Death of a family member: The loss of a loved one is an external stressor since it arises from an environmental and situational event outside the individual’s control. The stress reaction follows the external occurrence.

C. Fear of medical test results: Fear is an internal stressor because it originates from the individual’s own thoughts, emotions, and perceptions. It reflects how the person interprets and responds to a situation, even before external outcomes are known.

D. Job transfer to another city: A job transfer is an external stressor because it is an environmental change imposed on the individual. The stress arises from circumstances in the person’s surroundings rather than internal feelings.

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

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Naxlex Comprehensive Predictor Exams

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