A nurse is assessing a client who has received treatment for hypernatremia. Which of the following findings indicates the treatment has been effective?
Firm grip bilaterally
Fatigue
2+ deep tendon reflexes
Urine output 25 mL/hr
The Correct Answer is C
Choice A reason: A firm bilateral hand grip indicates normal muscle strength, which is a positive sign but not directly related to hypernatremia treatment efficacy.
Choice B reason: Fatigue is not a sign of effective treatment for hypernatremia. Fatigue can be a symptom of hypernatremia, as well as dehydration, infection, or other conditions. The nurse should assess the client for other causes of fatigue and monitor their vital signs and fluid status.
Choice C reason: Deep tendon reflexes graded as 2+ are considered normal and suggest that neuromuscular function is intact. Since hypernatremia can cause neuromuscular excitability, normal reflexes may indicate effective treatment.
Choice D reason: Urine output 25 mL/hr is not a sign of effective treatment for hypernatremia. Urine output 25 mL/hr is below the normal range of 30 to 50 mL/hr and indicates oliguria, which can be a complication of hypernatremia. Oliguria can result from dehydration, kidney damage, or reduced blood flow to the kidneys due to hypernatremia. The nurse should notify the provider and administer fluids as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is: b. Offer the client frozen bananas as a snack.
Choice A: Discourage the use of a straw
Discouraging the use of a straw is not the best intervention for a client with stomatitis following radiation therapy. While using a straw might cause some discomfort, it is not a primary concern. The focus should be on providing soothing and non-irritating foods.
Choice B: Offer the client frozen bananas as a snack
Offering the client frozen bananas as a snack is an appropriate intervention. Frozen bananas can provide a soothing effect on the inflamed oral tissues and are less likely to cause irritation compared to other foods. They are also nutritious and easy to consume, making them a suitable option for clients with stomatitis.
Choice C: Serve the client hot meals
Serving hot meals is not recommended for clients with stomatitis. Hot foods can exacerbate the discomfort and irritation in the mouth, making it more painful for the client to eat. It is better to serve foods at a moderate or cool temperature to avoid further irritation.
Choice D: Avoid serving sauces or gravies
Avoiding sauces or gravies is not the best intervention for a client with stomatitis. While some sauces or gravies might be irritating, others can be soothing and help make the food easier to swallow. The key is to choose mild and non-spicy options that do not irritate the oral tissues.
Correct Answer is C
Explanation
Choice A reason: Peas are not a good choice for a mechanical soft diet, as they are small and round and can pose a choking hazard. Peas also require some chewing to break them down, which may be difficult for the client.
Choice B reason: Dried apricots are not a good choice for a mechanical soft diet, as they are hard and sticky and can damage the teeth or dentures. Dried apricots also require a lot of chewing to swallow them, which may be painful or tiring for the client.
Choice C reason: Canned pears are a good choice for a mechanical soft diet, as they are soft and moist and can be easily mashed with a fork. Canned pears do not require much chewing and can be swallowed smoothly.
Choice D reason: Cashews are not a good choice for a mechanical soft diet, as they are hard and crunchy and can injure the gums or oral mucosa. Cashews also require a lot of chewing and can get stuck in the teeth or dentures.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
