A nurse is caring for a patient whose sodium level is 118 mEq/L. Which nursing diagnosis is a priority for this patient?

Comfort, Impaired

Disturbed Sensory Perception

Deficient Fluid Volume

Risk for Injury

Answer and Explanation

The Correct Answer is B

Choice A: Comfort, Impaired is not a priority nursing diagnosis for this patient, because this condition is not directly related to the low sodium level. Comfort, Impaired is a state of physical or psychological discomfort that can aﬀect the patient's well-being and quality of life.

Choice B: Disturbed Sensory Perception is a priority nursing diagnosis for this patient, because this condition is a serious complication of the low sodium level. Disturbed Sensory Perception is a state of altered or impaired perception of reality that can aﬀect the patient's cognitive and neurological functions. Low sodium level can cause cerebral edema, which is a swelling of the brain that can lead to confusion, seizures, coma, and death.

Choice C: Deficient Fluid Volume is not a priority nursing diagnosis for this patient, because this condition is not the cause of the low sodium level. Deficient Fluid Volume is a state of decreased intravascular, interstitial, or intracellular ﬂuid that can aﬀect the patient's ﬂuid and electrolyte balance. Low sodium level can be caused by excess ﬂuid intake, ﬂuid retention, or loss of sodium from the body.

Choice D: Risk for Injury is not a priority nursing diagnosis for this patient, because this condition is not specific to the low sodium level. Risk for Injury is a state of vulnerability to physical or psychological harm that can aﬀect the patient's safety and health. Low sodium level can increase the risk of injury from falls, accidents, or seizures.

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Correct Answer is ["A","C","D","E"]

Explanation

Choice A: Kussmaul respirations are a sign of metabolic acidosis, which is a condition that occurs when the body produces too much acid or loses too much bicarbonate. This can happen in patients with diabetes mellitus who develop diabetic ketoacidosis (DKA), a serious complication that results from insufficient insulin and high blood glucose levels. Kussmaul respirations are deep, rapid, and labored breathing that helps to eliminate excess carbon dioxide and acid from the blood.

Choice B: Cold, clammy skin is not a sign of metabolic acidosis, but rather of hypoglycemia, which is a condition that occurs when the blood glucose level is too low. This can happen in patients with diabetes mellitus who take too much insulin or oral hypoglycemic agents, skip meals, or exercise excessively. Cold, clammy skin is caused by vasoconstriction and sweating that occur as the body tries to increase blood glucose levels.

Choice C: Dysrhythmias are a sign of metabolic acidosis, because acidosis aﬀects the electrical activity of the heart and can cause irregular heartbeats. Dysrhythmias can also result from electrolyte imbalances, such as hyperkalemia, which is a condition that occurs when the blood potassium level is too high. This can happen in patients with metabolic acidosis who have impaired renal function and cannot excrete excess potassium.

Choice D: Tachycardia is a sign of metabolic acidosis, because acidosis stimulates the sympathetic nervous system and increases the heart rate. Tachycardia can also result from dehydration, which is a common complication of DKA due to excessive ﬂuid loss from vomiting, diarrhea, and polyuria.

Choice E: Weakness is a sign of metabolic acidosis because acidosis reduces the availability of oxygen and nutrients to the tissues and muscles. Weakness can also result from hypovolemia, which is a condition that occurs when the blood volume is too low. This can happen in patients with metabolic acidosis who have severe ﬂuid loss and hypotension.

A. Phosphorus B. Magnesium C. Potassium D. Calcium E. Sodium

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because phosphorus is not the most aﬀected electrolyte by acute renal failure. Phosphorus is a mineral that is involved in bone formation, energy metabolism, and acid-base balance. Acute renal failure can cause hyperphosphatemia, which is a high level of phosphorus in the blood, due to impaired excretion by the kidneys. However, hyperphosphatemia is usually asymptomatic and can be treated with phosphate binders and dietary restriction.

Choice B Reason: This is incorrect because magnesium is not the most aﬀected electrolyte by acute renal failure. Magnesium is a mineral that is essential for nerve and muscle function, blood pressure regulation, and bone health. Acute renal failure can cause hypermagnesemia, which is a high level of magnesium in the blood, due to impaired excretion by the kidneys. However, hypermagnesemia is rare and usually occurs in patients who receive excessive magnesium supplementation or antacids.

Choice C Reason: This is correct because potassium is the most aﬀected electrolyte by acute renal failure. Potassium is a mineral that is vital for nerve and muscle function, especially for the heart. Acute renal failure can cause hyperkalemia, which is a high level of potassium in the blood, due to impaired excretion by the kidneys. Hyperkalemia can cause muscle weakness, cardiac arrhythmias, and cardiac arrest. The nurse should monitor the patient's vital signs, electrocardiogram, and serum potassium level, and administer medications or dialysis as ordered.

Choice D Reason: This is incorrect because calcium is not the most aﬀected electrolyte by acute renal failure. Calcium is a mineral that is essential for muscle contraction, nerve transmission, and blood clotting. Acute renal failure can cause hypocalcemia, which is a low level of calcium in the blood, due to decreased production of active vitamin D by the kidneys. Hypocalcemia can cause tetany, seizures, and cardiac arrhythmias. The nurse should monitor the patient's vital signs, electrocardiogram, and Chvostek's and Trousseau's signs, and administer calcium and vitamin D supplements as ordered.

Choice E Reason: This is incorrect because sodium is not the most aﬀected electrolyte by acute renal failure. Sodium is a mineral that regulates ﬂuid balance, blood pressure, and nerve impulses. Acute renal failure can cause hyponatremia or hypernatremia, which are low or high levels of sodium in the blood, due to impaired regulation of water intake and output by the kidneys. Hyponatremia can cause confusion, seizures, and coma. Hypernatremia can cause thirst, agitation, and restlessness. The nurse should monitor the patient's ﬂuid balance, vital signs, and serum sodium level, and administer ﬂuids or diuretics as ordered.

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A nurse is caring for a patient whose sodium level is 118 mEq/L. Which nursing diagnosis is a priority for this patient?

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Naxlex Comprehensive Predictor Exams

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

The nurse is admitting a patient who was diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most aﬀected by this disorder?

Correct Answer is C

Explanation

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