The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

Urine output of 32 mL/hour.

Confusion and disorientation.

Blood pressure of 106/82.

2+ pedal edema bilaterally.

Answer and Explanation

The Correct Answer is B

A. A urine output of 32 mL/hour is slightly below the normal threshold (30 mL/hour) but does not indicate an immediate threat requiring intervention.
B. Confusion and disorientation are signs of severe hyponatremia, which can lead to cerebral edema and life-threatening complications such as seizures or coma. This finding requires immediate intervention to prevent worsening neurological impairment.
C. A blood pressure of 106/82 is within an acceptable range and does not indicate a critical issue in this context.
D. Bilateral 2+ pedal edema is not uncommon in elderly clients and does not directly indicate a severe complication of hyponatremia requiring immediate action.

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Correct Answer is D

Explanation

A. An inverted P wave is not typically associated with hypokalemia but may indicate other conduction abnormalities such as atrial ectopic rhythms.
B. A wide QRS complex is more commonly associated with hyperkalemia rather than hypokalemia. It may also indicate other conduction delays or ventricular issues.
C. An elevated ST segment suggests myocardial injury or pericarditis, not hypokalemia.
D. A flattened T wave is a hallmark of hypokalemia. Low potassium levels affect the repolarization phase of the cardiac cycle, leading to T wave flattening or inversion and, in severe cases, the presence of a U wave.

A. Excessive thirst B. Anxiety and tremors C. Excessive urination D. "Acetone" or "fruity" breath odor E. Slow, shallow respirations

Correct Answer is ["A","C","D"]

Explanation

A. Excessive thirst (polydipsia) is a common symptom of hyperglycemia due to dehydration caused by increased urination.
B. Anxiety and tremors are more commonly associated with hypoglycemia (low blood sugar), not hyperglycemia.
C. Excessive urination (polyuria) is a hallmark of hyperglycemia as the body attempts to excrete excess glucose through urine.
D. "Acetone" or "fruity" breath odor is a characteristic sign of diabetic ketoacidosis (DKA), which can occur in severe hyperglycemia.
E. Slow, shallow respirations are not typically associated with hyperglycemia but may occur in cases of respiratory acidosis or DKA, where Kussmaul's breathing (deep, rapid breathing) is more common.

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The nurse is assessing an elderly client admitted for hyponatremia. Which of the following findings requires immediate intervention?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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