A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?

Hyporeflexia.

Constipation.

Increased appetite.

Headache.

Answer and Explanation

The Correct Answer is D

The correct answer is Choice D: Headache.

Rationale for Choice D (Headache): Hyponatremia, defined as a serum sodium level below 135 mEq/L, can lead to various neurological symptoms due to the altered osmotic pressure in the brain cells. When the sodium level drops below normal, water moves into the cells, causing them to swell, which can lead to increased intracranial pressure and subsequent headaches. Therefore, a client with a sodium level of 128 mEq/L is likely to experience headaches as a manifestation of hyponatremia.

Rationale for other choices:

Choice A: Hyporeflexia Hyporeflexia refers to diminished or absent reflexes. While hyponatremia can affect neurological function, hyporeflexia is not a typical manifestation. Instead, hyperreflexia may occur in severe cases due to cerebral edema and increased intracranial pressure.

Choice B: Constipation Constipation is not a common manifestation of hyponatremia. Gastrointestinal symptoms such as nausea, vomiting, and abdominal cramping may occur, but constipation is not typically associated with sodium imbalances.

Choice C: Increased appetite Hyponatremia does not typically cause increased appetite. Instead, gastrointestinal symptoms such as nausea and anorexia are more commonly observed. Increased appetite is not directly related to sodium levels but may be seen in conditions such as hyperthyroidism or certain medications.

Therefore, based on the provided data and typical manifestations of hyponatremia, the correct answer is Choice D: Headache. This is because headaches are a common neurological symptom associated with low sodium levels and increased intracranial pressure.

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Correct Answer is B

Explanation

Choice A rationale:
Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA) to help prevent airway obstruction during sleep. However, this should not be the nurse's immediate priority before leaving the client. Ensuring the client's positive airway pressure (PAP) device is properly applied is more crucial.
Choice C rationale:
While locking the side rails in place is generally essential for safety, it is not the most critical intervention for a client with OSA and urination issues. Ensuring proper use of the PAP device is a higher priority.
Choice D rationale:
Removing dentures or other oral appliances is important for preventing airway obstruction in clients with OSA, but it should not take precedence over ensuring the use of the PAP device. The nurse should address the immediate respiratory needs of the client.

A. Metabolic alkalosis. B. Metabolic acidosis. C. Respiratory alkalosis. D. Respiratory acidosis.

Correct Answer is A

Explanation

Choice A rationale:

Metabolic alkalosis Metabolic alkalosis is characterized by an elevated pH (above the normal range of 7.35-7.45) and an increased bicarbonate (HCO3) level (above the normal range of 22-28 mEq/L). In this case, the client's pH of 7.6 and HCO3 level of 32 mEq/L indicate a primary metabolic alkalosis. It can be caused by excessive bicarbonate intake, loss of acid (as in vomiting or excessive diuretic use), or other factors that result in an excess of bicarbonate in the body. The PaCO2 level is within the normal range (35-45 mm Hg), which is consistent with compensatory hypoventilation seen in metabolic alkalosis.

Choice B rationale:

Metabolic acidosis Metabolic acidosis is characterized by a decreased pH and bicarbonate level. The client's ABG results do not align with metabolic acidosis. In this case, the pH is elevated, and the bicarbonate level is above the normal range.

Choice C rationale:

Respiratory alkalosis Respiratory alkalosis is characterized by an elevated pH and decreased PaCO2. The client's ABG results show a normal PaCO2 of 40 mm Hg, which does not align with respiratory alkalosis. In respiratory alkalosis, you would typically see a lower PaCO2.

Choice D rationale:

Respiratory acidosis Respiratory acidosis is characterized by a decreased pH and elevated PaCO2. The client's ABG results do not align with respiratory acidosis. In this case, the PaCO2 is within the normal range, and the pH is elevated, which is not indicative of respiratory acidosis.

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A nurse is collecting data from a client who has a sodium level of 128 mEq/L. Which of the following manifestations should the nurse expect?

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