A patient is being admitted to the floor following a motor vehicle accident. because of the stressful nature of the event, the nurse anticipates the patient will continue to have a sympathetic reaction during the post operative period. When monitoring the patient's serum electrolytes, what will the nurse closely monitor?
Increased calcium
Deceased sodium
Decreased potassium
Increased chloride
The Correct Answer is C
A) Increased calcium: Sympathetic activation typically does not cause a direct increase in calcium levels. Calcium levels are more influenced by factors like parathyroid hormone (PTH) and vitamin D, or conditions such as bone disease or renal issues. Although some stress responses can lead to changes in calcium metabolism, an increase in calcium is not a typical response to sympathetic activation.
B) Decreased sodium: While sodium imbalances can occur in various conditions, the sympathetic nervous system does not directly cause a decrease in sodium. The body's handling of sodium is more influenced by factors like kidney function and the renin-angiotensin-aldosterone system. Stress-related changes in sodium levels are less likely to cause a significant decrease in sodium, making this an unlikely focus in monitoring.
C) Decreased potassium: During stress, the body releases catecholamines (like epinephrine) as part of the sympathetic nervous response, which stimulates the movement of potassium into cells. This can result in a transient decrease in serum potassium levels (hypokalemia). Monitoring for decreased potassium is important, as low potassium can lead to cardiac arrhythmias and muscle weakness, which are particularly concerning after surgery or trauma.
D) Increased chloride: Chloride is typically maintained in balance with sodium, and while it may shift in certain conditions, sympathetic activation does not directly lead to increased chloride levels. Most chloride imbalances are secondary to changes in sodium, acid-base disturbances, or kidney function. Therefore, an increase in chloride is less likely in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Decreased bowel sounds:
When the sympathetic nervous system (SNS) is activated, such as during stress or a "fight-or-flight" response, blood is redirected away from the gastrointestinal (GI) tract to vital organs like the heart and muscles. This results in decreased gastrointestinal motility and function, which is reflected in a reduction in bowel sounds. Decreased bowel sounds are a direct consequence of reduced blood flow and decreased activity in the GI system.
B) Increased blood glucose level:
While it is true that SNS activation can lead to an increase in blood glucose due to the release of catecholamines (e.g., epinephrine), this response is related to the body’s preparation for physical exertion and not directly a result of blood being diverted from the GI tract. The increase in glucose levels is more about energy mobilization rather than an effect on blood flow to the GI tract.
C) Decreased immune reaction:
Sympathetic stimulation can indeed have effects on immune function, typically suppressing immune responses during a stress response. However, this is not directly linked to blood being diverted away from the GI tract. Immune suppression is more about the body prioritizing immediate survival (e.g., diverting energy to muscles for fight-or-flight) rather than a specific physiological consequence of GI blood flow changes.
D) Increased blood pressure:
Sympathetic nervous system activation does lead to an increase in blood pressure due to vasoconstriction and increased heart rate. However, increased blood pressure is a broader systemic response to SNS stimulation, and it is not directly related to blood being diverted from the GI tract. Blood pressure increases as part of the general "fight-or-flight" response, but it does not specifically indicate changes in GI blood flow.
Correct Answer is C
Explanation
A) Risk for dehydration related to diarrhea:
Diarrhea is not a common issue directly associated with Parkinson’s disease or its typical treatments, such as dopaminergic medications. While some medications or conditions can cause gastrointestinal disturbances, dehydration due to diarrhea is not a primary concern in Parkinson’s disease.
B) Diarrhea related to dopaminergic effects:
Dopaminergic medications, such as levodopa, may cause gastrointestinal side effects, but diarrhea is not a primary or common side effect. Typically, dopaminergic effects can lead to constipation, not diarrhea.
C) Risk for injury related to CVS effects and incidence of orthostatic hypotension:
Parkinson's disease can cause autonomic dysfunction, which often leads to orthostatic hypotension increasing the risk of falls and injury. This is a valid and appropriate nursing diagnosis because patients with Parkinson’s disease often experience balance issues and dizziness due to this condition, making them more vulnerable to falls and injury.
D) Constipation related to dopaminergic effects:
While constipation is a common side effect of dopaminergic medications used to treat Parkinson's disease, the more appropriate diagnosis for a patient who has Parkinson’s disease would be one that addresses the immediate risks or complications related to mobility or autonomic dysfunction.
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