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 C

Explanation

A. The grieving process should be complete within 1 year.: This is incorrect. Grief is a highly individual process and does not follow a strict timeline. It can last longer than one year for some individuals, depending on the relationship and circumstances.

B. Anticipatory grieving prolongs the grief process.: This is incorrect. Anticipatory grief, the grief experienced before the loss occurs, does not necessarily prolong the grieving process. In fact, it may help some individuals cope better after the loss because they have already begun to process their emotions.

C. Anger toward the health care staff is expected.: This is correct. It is normal for family members to experience anger during the grieving process, and sometimes they may direct it toward the healthcare staff, especially if they feel that the care is inadequate or if they are overwhelmed by emotions.

D. The stages of grief occur in sequential order.: This is incorrect. While Elisabeth Kübler-Ross identified five stages of grief (denial, anger, bargaining, depression, and acceptance., they do not necessarily occur in a linear or sequential order. Individuals may experience them in different ways and revisit stages at different times.

A. Use hot water to wash hands. B. Apply friction to hands for 10 seconds. C. Dry hands starting from forearm to fingers. D. Interlace the fingers while rubbing hands together.

Correct Answer is D

Explanation

A. Using hot water to wash hands is incorrect. Hot water can cause skin irritation and is not necessary for effective hand hygiene. The water temperature should be comfortable for the person washing their hands, whether it is warm or cool.

B. Applying friction to hands for 10 seconds is incorrect. Hand hygiene should be done for at least 20 seconds, not just 10 seconds, to effectively remove contaminants.

C. Drying hands starting from forearm to fingers is incorrect. Hands should be dried starting from the fingers to the forearms to avoid contamination from dripping water on the hands after washing. The goal is to maintain clean hands throughout the drying process.

D. Interlacing the fingers while rubbing hands together is correct. Interlacing the fingers and rubbing them together ensures that all surfaces of the hands, including between the fingers, are properly cleaned. This method is recommended in the CDC hand hygiene guidelines for thorough washing.

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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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