As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?

Hyperchloremia

Hypercalcemia

Hypocalcemia

Hypomagnesemia

Answer and Explanation

The Correct Answer is C

Choice A reason: Hyperchloremia, elevated chloride levels, is associated with metabolic acidosis or dehydration, not neuromuscular symptoms like wrist flexion. Chloride imbalances affect acid-base balance, not calcium-dependent muscle contractions. The inward wrist flexion suggests a neuromuscular excitability issue, which is more characteristic of low calcium levels than chloride abnormalities.

Choice B reason: Hypercalcemia, high calcium levels, causes muscle weakness, lethargy, and reduced reflexes, not increased neuromuscular excitability like wrist flexion. Calcium excess stabilizes nerve membranes, reducing spasms. The symptom described aligns with hypocalcemia, where low calcium increases nerve excitability, leading to tetany or abnormal muscle contractions.

Choice C reason: Hypocalcemia, low calcium levels, increases neuromuscular excitability due to decreased stabilization of nerve membranes. This can cause tetany, characterized by involuntary muscle contractions, such as wrist flexion (carpopedal spasm). The symptom is a classic sign of hypocalcemia, often seen in conditions like hypoparathyroidism or vitamin D deficiency.

Choice D reason: Hypomagnesemia, low magnesium, can cause neuromuscular symptoms like tremors or seizures but is less commonly associated with specific signs like wrist flexion. Magnesium affects muscle relaxation, and its deficiency typically causes generalized excitability. Hypocalcemia is more directly linked to tetany and carpopedal spasms, as seen in the client.

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Correct Answer is B

Explanation

Choice A reason: Fluid volume deficit, or hypovolemia, involves decreased fluid volume, causing symptoms like dehydration and hypotension. Heart failure leads to fluid retention due to poor cardiac output, resulting in edema and lung crackles, which are signs of fluid overload, not deficit, making this an incorrect diagnosis.

Choice B reason: Fluid volume excess, or hypervolemia, occurs in heart failure when the heart’s reduced pumping capacity causes fluid backup, leading to edema and pulmonary congestion (crackles). This matches the client’s symptoms, as ineffective cardiac output increases venous pressure, causing fluid to accumulate in tissues and lungs.

Choice C reason: Myocardial infarction is a heart attack caused by coronary artery occlusion, leading to myocardial ischemia. While it can cause heart failure, the client’s symptoms of edema and crackles specifically indicate fluid volume excess due to heart failure, not the acute event of infarction itself.

Choice D reason: Atelectasis is lung collapse due to airway obstruction or compression, causing reduced breath sounds, not crackles. Heart failure’s pulmonary edema causes coarse crackles due to fluid in alveoli. Atelectasis does not explain the client’s edema or fluid-related symptoms, making it an incorrect choice.

A. Increase sodium intake to maintain electrolyte balance B. Consume a diet high in saturated fats C. Follow a DASH diet rich in fruits and vegetables D. Limit potassium-rich foods to prevent fluid retention

Correct Answer is C

Explanation

Choice A reason: Increasing sodium intake raises blood pressure by promoting fluid retention, increasing vascular volume, and straining the cardiovascular system. Hypertensive clients need sodium restriction to reduce fluid overload and vascular resistance, making this recommendation harmful, as it exacerbates hypertension rather than controlling it.

Choice B reason: A diet high in saturated fats contributes to atherosclerosis, increasing vascular resistance and blood pressure. It also raises LDL cholesterol, worsening cardiovascular risk. Hypertensive clients require heart-healthy diets low in saturated fats to reduce blood pressure and protect against heart disease, making this inappropriate.

Choice C reason: The DASH (Dietary Approaches to Stop Hypertension) diet, rich in fruits, vegetables, and low-fat dairy, reduces blood pressure by providing potassium, magnesium, and fiber. These nutrients lower vascular resistance and promote vasodilation, improving cardiovascular health. It is evidence-based and recommended for hypertension management, making it the best choice.

Choice D reason: Limiting potassium-rich foods is not recommended for hypertension, as potassium promotes vasodilation and reduces blood pressure by counteracting sodium’s effects. Potassium-rich foods, like fruits, are part of the DASH diet, which helps control hypertension, making this recommendation incorrect for blood pressure management.

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As the nurse assesses a client’s blood pressure, the patient’s wrist severely flexes inward. The nurse questions the client’s response because this finding may indicate what condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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