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?"

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Pacing the client's care to provide periods of rest is important for managing fatigue and preventing overexertion. However, it is not the first action the nurse should take in this situation. Monitoring vital signs is crucial to assess the client's current condition and detect any immediate complications.

Choice B reason: Making arrangements for radioactive iodine therapy is a treatment option for hyperthyroidism. However, this is not the first action the nurse should take. The nurse needs to assess the client's condition and stabilize any immediate issues before considering long-term treatment options.

Choice C reason: Administering a beta-adrenergic blocking agent can help manage symptoms such as a racing heartbeat and nervousness. While this may be part of the treatment plan, it is not the first action the nurse should take. Monitoring vital signs is essential to determine the appropriate interventions.

Choice D reason: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.

A. Pain in lower legs when walking. B. Black eschar over ankle ulcer. C. Absent pedal pulses by Doppler. D. Dependent rubor of lower extremities.

Correct Answer is C

Explanation

Choice A reason: Pain in the lower legs when walking, also known as intermittent claudication, is a common symptom of PAD but does not indicate an immediate threat to limb viability.

Choice B reason: Black eschar over the ankle ulcer indicates necrotic tissue, which is concerning but not as immediately critical as absent pulses. It does need to be monitored and treated to prevent infection and further complications.

Choice C reason: Absent pedal pulses by Doppler indicate a significant reduction in blood flow to the lower extremities, which can lead to critical limb ischemia and requires immediate intervention to restore perfusion and prevent tissue loss.

Choice D reason: Dependent rubor (redness when the leg is in a dependent position) is a sign of poor arterial circulation but does not require as urgent intervention as absent pedal pulses.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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