A nurse is planning care for a client who is admitted with a serum sodium level of 115 mEq/L. Which assessment finding is most important for the client?

Serum osmolality

Neurologic status

Skin turgor

Urine output

Answer and Explanation

The Correct Answer is B

A. Serum osmolality will undoubtedly be low in a client with a sodium level of 115 mEq/L, as sodium is the primary determinant of plasma tonicity. While this lab value confirms the state of hyponatremia, it does not provide immediate information about the client's physiological response to the electrolyte imbalance. The nurse uses osmolality as a diagnostic tool, but it is secondary to the assessment of active clinical symptoms.

B. Neurologic status is the priority assessment because profound hyponatremia causes an osmotic shift of water into the brain cells, leading to cerebral edema. At levels as low as 115 mEq/L, the client is at extreme risk for seizures, coma, and permanent neurological damage or brain herniation. Monitoring for changes in level of consciousness or seizure activity is critical for ensuring safety during the careful restoration of sodium levels.

C. Skin turgor is a physical assessment tool used to estimate the client's hydration status, but it is not a reliable or specific indicator of the severity of hyponatremia. Turgor can be affected by age, chronic illness, and the specific etiology of the sodium deficit, such as fluid overload versus depletion. In the presence of life-threatening electrolyte levels, skin assessments are far less urgent than monitoring for central nervous system dysfunction.

D. Urine output provides data regarding renal function and the potential cause of the hyponatremia, such as the syndrome of inappropriate antidiuretic hormone (SIADH) or diuretic use. However, monitoring output does not address the immediate life-threatening risk posed by the intracellular swelling of neurons in the brain. The nurse must focus on the most critical organ system affected by the low sodium concentration to prevent catastrophic outcomes.

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Correct Answer is B

Explanation

A.Sanguineous drainage represents active bleeding or fresh bloody discharge from an open wound or incision. While it may accompany an injury, it is not one of the five cardinal signs of the localized inflammatory response. Inflammation can occur in closed tissue injuries, such as a sprain, where no external drainage is present but internal cellular changes are occurring.

B.Increased warmth, or calor, is a cardinal sign of inflammation caused by localized vasodilation and increased blood flow to the injured area. Chemical mediators like histamine and bradykinin cause the capillaries to widen, bringing warmer core blood to the surface of the affected tissue. This physiological response is intended to deliver leukocytes and nutrients necessary for the tissue repair process.

C.Palpable pedal pulses indicate adequate arterial perfusion to the distal extremity but are not a result of the inflammatory process itself. In cases of severe localized inflammation and edema, pressure on the vasculature can actually diminish the strength of distal pulses. While the nurse should assess for pulses, their presence is a sign of normal circulatory function rather than an inflammatory manifestation.

D.A full range of motion is typically lost during localized inflammation due to pain and swelling (tumor) within the joint or surrounding soft tissue. Edema increases interstitial pressure, which mechanically restricts movement, while inflammatory mediators sensitize nociceptors to produce pain during activity. Expecting a full range of motion in a newly injured, inflamed ankle is clinically inconsistent with inflammatory pathophysiology.

A. Take the flu vaccine annually B. Taking an iron supplement daily C. Frequent handwashing D. Maintaining adequate hydration

Correct Answer is D

Explanation

A.Annual influenza vaccination is an important health maintenance strategy for all clients to prevent respiratory complications and secondary infections. While infection can trigger a sickle cell crisis, this generalized preventative measure is not the most specific or immediate strategy for preventing the vaso-occlusive events that define the disease. The nurse should include it in a broader teaching plan but prioritize more direct triggers.

B.Daily iron supplements are typically contraindicated for clients with sickle cell anemia unless a true iron deficiency is laboratory-confirmed. Because these clients undergo chronic hemolysis and may receive frequent blood transfusions, they are at a significant risk for iron overload and subsequent organ damage, a condition known as hemosiderosis. The nurse must educate the client to avoid over-the-counter iron preparations to prevent systemic toxicity.

C.Frequent handwashing is a fundamental infection control practice that reduces the risk of contracting communicable diseases which could stress the body and precipitate a crisis. While essential for overall health, it specifically targets the external environment rather than the internal physiological conditions that lead to the sickling of erythrocytes. It serves as a supportive measure rather than a primary intervention for preventing vaso-occlusion.

D.Maintaining adequate hydration is the most critical strategy because dehydration increases blood viscosity and promotes the sickling of hemoglobin S. Increased fluid intake helps to dilute the concentration of sickled cells and ensures smooth transit through the microvasculature, thereby preventing the pain and tissue ischemia associated with a crisis. The nurse must emphasize consistent oral fluid intake to maintain hemodynamic stability and prevent stasis.

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