The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?
"Do you drink milk or eat dairy products at each meal?"
"How much water and ice chips do you have each day?"
"What amount of your daily meals contains fresh vegetables?"
"How frequently do you eat processed or canned foods?"
The Correct Answer is B
Choice A reason: Asking about the consumption of milk or dairy products is not directly related to the client's serum sodium level. Dairy intake does not typically cause significant changes in sodium levels. Therefore, this question would not help in identifying the cause of the hyponatremia.
Choice B reason: This question is most relevant because excessive water or ice chip intake can lead to dilutional hyponatremia. Ingestion of large amounts of water can dilute the sodium concentration in the blood, resulting in a low serum sodium level. Identifying excessive fluid intake is critical in determining if this is the cause of the client's hyponatremia.
Choice C reason: Inquiring about the number of fresh vegetables in the client's diet is more related to overall nutrition rather than directly linked to sodium levels. While vegetables can be part of a healthy diet, this question would not specifically address the cause of a low serum sodium level.
Choice D reason: The frequency of consuming processed or canned foods, which are typically high in sodium, would generally be expected to increase serum sodium levels rather than decrease them. Therefore, this question does not directly address the issue of a low sodium level.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Assessing peripheral pulses is important for understanding the client's overall circulatory status, but it is not the most urgent assessment in this situation. The client's symptoms suggest a possible thyrotoxic crisis, which requires immediate evaluation of critical vital signs.
Choice B reason: Obtaining vital signs is the most important initial assessment. The client's report of anxiety, heart racing, and pounding could indicate a severe exacerbation of hyperthyroidism, potentially leading to a thyrotoxic crisis (thyroid storm). Vital signs will provide essential information on the client's heart rate, blood pressure, temperature, and overall stability, which are crucial for immediate management.
Choice C reason: The presence of a goitre can indicates thyroid gland enlargement, which is relevant for long-term management of hyperthyroidism. However, it does not provide immediate information on the client's current acute condition.
Choice D reason: Assessing emotional status is important for comprehensive care, but it is not the priority in this acute scenario. The client's physiological status needs to be stabilized first, as indicated by their vital signs, before focusing on their emotional state.
Correct Answer is B
Explanation
Choice A reason: While it is important for the client to accept their new health status, this outcome is subjective and difficult to measure. The focus should be on specific, measurable outcomes related to diabetes management.
Choice B reason: A haemoglobin A1C level of less than 7.0% in 3 months is a specific, measurable outcome that indicates good control of blood glucose levels. It reflects adherence to the prescribed diabetic regimen and effective management of the condition.
Choice C reason: Educating the client's family about the signs and symptoms of diabetes is important, but it is more of a teaching objective rather than a measurable outcome for the client's plan of care.
Choice D reason: Monitoring the client's skin condition for colour changes is part of routine care but does not directly address the management of diabetes or measure the effectiveness of the treatment plan.
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