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 ["A","D"]
Explanation
A. Review strategies to reduce sodium intake:
This educational method involves providing information and teaching the client specific strategies to reduce sodium intake, such as reading food labels, avoiding high-sodium processed foods, and choosing fresh fruits and vegetables. It engages the cognitive domain of learning as it focuses on acquiring knowledge and understanding of the topic.
B. Ask the client how they are feeling about starting a low sodium diet:
This educational method involves exploring the client's feelings and emotions regarding the low sodium diet. It primarily engages the affective domain of learning, which focuses on attitudes, beliefs, and feelings.
C. Observe the client choose low sodium foods:
This educational method involves observing the client's behavior and actions. It primarily engages the psychomotor domain of learning, which focuses on physical skills and actions.
D. Discuss the physiology of hypertension with the client:
This educational method involves explaining the underlying physiology of hypertension, including factors such as sodium intake, blood pressure regulation, and cardiovascular health. It engages the cognitive domain of learning as it focuses on acquiring knowledge and understanding of the physiological processes involved in hypertension.
E. Encourage the client to share their thoughts in a support group:
This educational method involves providing opportunities for the client to share their thoughts and experiences with others in a support group setting. It primarily engages the affective domain of learning, which focuses on attitudes, beliefs, and feelings.
Correct Answer is A
Explanation
A. The ST segment is elevated above the isoelectric line: This is correct. ST-segment elevation is a key ECG finding in acute myocardial infarction. It indicates that a portion of the heart muscle is not receiving enough blood (ischemia), which can lead to tissue damage or death (infarction).
B. The PR intervals are 0.15 second: While the PR interval is an important part of the ECG, a PR interval of 0.15 second is within the normal range and does not indicate an acute myocardial infarction.
C. The QT interval is equal to the R to R interval: The QT interval represents the time from the start of the Q wave to the end of the T wave, encompassing ventricular depolarization and repolarization. While prolonged or shortened QT intervals can be associated with certain cardiac conditions, they are not specific indicators of an acute myocardial infarction.
D. The QRS intervals are 0.08 second: The QRS interval represents ventricular depolarization1. A QRS interval of 0.08 second is within the normal range and does not indicate an acute myocardial infarction.
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