A nurse is collecting data from a client who has heart failure and takes chlorothiazide sodium. Which of the following findings should the nurse identify as indicating hypokalemia?
Restlessness
Hyperactive bowel sounds
Decreased deep-tendon reflexes
Bounding peripheral pulses
The Correct Answer is C
A. Restlessness:
Restlessness is not typically associated with hypokalemia. Instead, it may indicate anxiety, discomfort, or other factors unrelated to electrolyte imbalances.
B. Hyperactive bowel sounds:
Hyperactive bowel sounds are often associated with increased gastrointestinal motility, which may occur in conditions such as diarrhea or gastroenteritis. While electrolyte imbalances can contribute to gastrointestinal symptoms, hyperactive bowel sounds are not specific to hypokalemia.
C. Decreased deep-tendon reflexes:
Hypokalemia can lead to decreased deep-tendon reflexes due to its effects on nerve conduction. Potassium is essential for proper nerve and muscle function, and low levels can impair reflexes.
D. Bounding peripheral pulses:
Bounding peripheral pulses are not typically associated with hypokalemia. Instead, they may indicate increased cardiac output or volume overload, which can occur in conditions such as heart failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
(A) "A heating pad will be used on the operative site to help reduce pain.":
Using a heating pad on the operative site is generally not recommended post-surgery, as it can increase bleeding and swelling. Cold therapy is usually preferred to help reduce pain and inflammation.
(B) "You will use a continuous passive motion (CPM) machine several times a day.":
Continuous passive motion machines are typically used after knee replacement surgeries, not hip replacement surgeries. Therefore, this statement would not be accurate for a total hip replacement.
(C) "Expect to remain in bed for at least the first 24 hours.":
Early mobilization is crucial after hip replacement surgery to prevent complications such as deep vein thrombosis and to promote recovery. Patients are usually encouraged to get out of bed and start moving with assistance as soon as possible, often within the first 24 hours.
(D) "You will use a special soap to shower with the evening before your surgery.":
Using a special antiseptic soap before surgery is a common preoperative instruction to help reduce the risk of infection. This statement is correct and should be included in the preoperative teaching.
Correct Answer is D
Explanation
A. A 14-month-old toddler with bruises on bony prominences:
Bruises on bony prominences are common in toddlers who are learning to walk and are prone to falls. While bruising can raise concerns, it is not necessarily indicative of physical abuse, especially in this age group.
B. A 9-month-old infant who sustained near drowning:
Near drowning in an infant who climbed into the tub and turned on the water suggests an accidental event rather than physical abuse. This scenario is consistent with lack of supervision or an unfortunate accident.
C. A 3-year-old toddler with scalding burns:
Scalding burns from spilling hot tea on oneself can occur accidentally, especially in young children who may not understand the dangers associated with hot liquids. While the circumstances may raise suspicion, it does not necessarily indicate physical abuse without further evidence.
D. A 6-year-old child with a spiral fracture:
A spiral fracture of the tibia and fibula is concerning for physical abuse, especially in a child who reportedly sustained the injury while riding a bicycle. Spiral fractures are often associated with twisting or pulling forces and are considered suspicious for non-accidental trauma, particularly when there is no plausible explanation for the injury.
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