A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect?

Nausea and vomiting

Altered mental status

Dysrhythmias

Hypothermia

Answer and Explanation

The Correct Answer is B

A. Nausea and vomiting: Nausea and vomiting can be present with hypernatremia (high sodium levels), but they are not the most prominent or specific symptom. The client may experience these symptoms, but they are usually accompanied by other signs.

B. Altered mental status: This is a common manifestation of hypernatremia. The elevated sodium level causes an osmotic imbalance, leading to water shifting out of cells, which results in neurological symptoms, including confusion, lethargy, or seizures.

C. Dysrhythmias: Dysrhythmias can occur with electrolyte imbalances, including hypernatremia, but the primary symptoms related to sodium levels are more often neurological in nature, such as confusion or altered mental status, rather than dysrhythmias specifically.

D. Hypothermia: Hypernatremia typically causes an increase in body temperature, not hypothermia. Elevated sodium levels cause dehydration, which could contribute to increased body temperature rather than cooling.

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Correct Answer is B

Explanation

A. "Apply rubber-soled slippers before ambulation.": This is important for safety, but it is not the first step in fall prevention. The client needs to be able to call for assistance if needed before moving around.

B. "Determine the client's ability to use the call light.": This should be the first step. Ensuring that the client can easily use the call light in case they need help is a foundational fall prevention strategy. It is essential for maintaining the client’s safety and enabling them to request assistance when needed.

C. "Create a schedule with an assistive personnel to do hourly rounding for the client.": Hourly rounding is an important fall prevention measure, but it should follow initial steps such as ensuring the client can call for help. It can be implemented after determining how the client will communicate needs.

D. "Move the bedside table with the client's personal items close to the bed.": This is a helpful precaution, as it reduces the need for the client to reach or stand to access their belongings. However, the most critical initial step is ensuring the client can safely summon help if needed.

A. Productive cough with pink, frothy sputum B. Weight loss of 1 kg (2.2 lB. in the past 24 hr C. Fatigue when ambulating 152 m (500 ft)

Correct Answer is A

Explanation

A. "Productive cough with pink, frothy sputum": This is a concerning finding that should prompt immediate notification to the provider. It is indicative of pulmonary edema, which can occur with left-sided heart failure as fluid backs up into the lungs. Pink, frothy sputum is a classic sign of this condition and requires urgent intervention.

B. "Weight loss of 1 kg (2.2 lB. in the past 24 hr": Weight loss is generally not a primary concern in left-sided heart failure. In fact, weight loss could be a result of fluid loss from diuretics or other interventions. A small weight change like this is not likely to be significant unless the client shows signs of dehydration or malnutrition.

C. "Fatigue when ambulating 152 m (500 ft)": Fatigue with activity is common in clients with left-sided heart failure, as reduced cardiac output and impaired oxygenation of tissues can cause fatigue during exertion. However, this is not an acute finding that would require immediate intervention.

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A nurse is collecting data from a client who has a sodium level of 156 mEq/L. Which of the following findings should the nurse expect?

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