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 B

Explanation

Choice A reason: A bounding peripheral pulse indicates increased arterial circulation and is not a sign of compromised peripheral arterial circulation. In cases of arterial insufficiency, pulses may actually be diminished or absent.

Choice B reason: Uneven hair distribution is a classic sign of compromised peripheral arterial circulation. Poor blood flow to the extremities can lead to decreased hair growth, causing patchy or uneven hair distribution. This symptom is often seen in clients with peripheral arterial disease.

Choice C reason: Lower leg enema is more commonly associated with venous insufficiency rather than arterial insufficiency. Edem results from fluid accumulation due to poor venous return rather than issues with arterial circulation.

Choice D reason: Bronze pigmentation is often related to chronic venous insufficiency and hemosiderin deposition in the skin. It is not typically a sign of compromised arterial circulation. Arterial issues are more likely to cause pallor or cyanosis in the affected extremity.

A. Occult positive emesis. B. Strong foul-smelling flatus. C. Report of poor night vision. D. Loose bowel movements.

Correct Answer is A

Explanation

Choice A reason: Occult positive emesis, which indicates the presence of blood in vomit, is a critical finding. It suggests potential gastrointestinal bleeding, which requires immediate medical intervention. This condition can lead to significant blood loss and further complications if not addressed promptly.

Choice B reason: Strong foul-smelling flatus can indicate malabsorption or changes in gut flora, which are common after biliopancreatic diversion. While it can be unpleasant and concerning, it is not as immediately dangerous as gastrointestinal bleeding.

Choice C reason: A report of poor night vision could be related to vitamin A deficiency, which can occur after malabsorptive procedures like BPD. However, it is not an immediate threat compared to the risk of gastrointestinal bleeding.

Choice D reason: Loose bowel movements are common after BPD due to changes in digestion and absorption. While they can contribute to dehydration, they are not as urgent as the presence of blood in vomit.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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