Which electrolyte imbalance should a nurse expect to assess in a client who reports diarrhea for the past three days?

Hypokalemia.

Hypocalcemia.

Hyponatremia.

Hypochloremia.

Answer and Explanation

The Correct Answer is A

This is because diarrhea can cause a loss of potassium along with water and other electrolytes. Potassium is an important mineral that helps regulate the heartbeat, nerve impulses and muscle contractions. Low levels of potassium can cause symptoms such as weakness, fatigue, muscle cramps, irregular heartbeat and constipation.

Choice B. Hypocalcemia is wrong because diarrhea does not usually cause a loss of

calcium. Calcium is another mineral that helps with muscle and nerve function, blood clotting and bone health. Low levels of calcium can cause symptoms such as numbness, tingling, muscle spasms, seizures and confusion.

Choice C. Hyponatremia is wrong because diarrhea can cause a loss of sodium, but not to the extent that it causes hyponatremia. Sodium is the most abundant electrolyte in the body and it helps regulate fluid balance, blood pressure and nerve and muscle function. Low levels of sodium can cause symptoms such as headache, confusion, nausea, vomiting, seizures and coma.

Choice D. Hypochloremia is wrong because diarrhea can cause a loss of chloride, but not to the extent that it causes hypochloremia. Chloride is another electrolyte that helps maintain fluid balance, blood pressure and acid-base balance. Low levels of chloride can cause symptoms such as weakness, dehydration, alkalosis (high blood pH) and muscle twitching.

The normal ranges for electrolytes in the blood are:

Potassium: 3.5 to 5 mEq/L
Calcium: 8.5 to 10.2 mg/dL
Sodium: 135 to 145 mEq/L
Chloride: 96 to 106

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Correct Answer is A

Explanation

Using an automatic BP cuff with a shivering client with a history of an irregular heart rate can result in inaccurate and low readings.

This is because shivering can interfere with the cuff inflation and deflation, and an irregular heart rate can affect the accuracy of the device.

The nurse should intervene and use a manual BP cuff with a stethoscope instead.

Choice B is wrong because pulling the client’s ear pinna backward, up and out to obtain a tympanic membrane temperature is the correct technique for adults and older children. This helps to straighten the ear canal and allow the light to reflect on the tympanic membrane, which shares the same vascular artery as the hypothalamus.

Choice C is wrong because counting the client’s radial pulse who is supine with the forearm straight alongside the body is an appropriate method.

The radial pulse can be easily palpated at the wrist, and the supine position and straight forearm do not affect the pulse rate.

Choice D is wrong because counting the respirations for one full minute for a client with tachypnea is a recommended practice.

Tachypnea means rapid breathing, and counting for one full minute can ensure accuracy and detect any variations in the respiratory pattern.

A. Adding a nursing diagnosis of lowered self-esteem to the care plan. B. Giving praise for every decision the client makes. C. Eliciting client input into planning care. D. Modeling competent care for the client.

Correct Answer is C

Explanation

This would help the client to feel valued, respected and involved in their own care, which can enhance their self-esteem.

Choice A is wrong because adding a nursing diagnosis of lowered self-esteem to the care plan does not address the underlying causes of the problem or provide any interventions to improve it.

It may also label the client and make them feel worse.

Choice B is wrong because giving praise for every decision the client makes is not realistic or sincere.

It may also undermine the client’s confidence and autonomy by implying that they need constant approval from others.

Choice D is wrong because modeling competent care for the client does not necessarily help them to maintain their self-esteem.

It may even make them feel inadequate or dependent on the nurse.

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Which electrolyte imbalance should a nurse expect to assess in a client who reports diarrhea for the past three days?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes the unlicensed assistive personnel (UAP) obtain vital signs on four adult clients. For which client should the nurse intervene to redirect to use of proper method?

Correct Answer is A

Explanation

Which nursing intervention would best assist a hospitalized client to maintain self-esteem?

Correct Answer is C

Explanation

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