Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017) - Fluid and Electrolytes: Balance and Disturbance

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A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?

  • A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
  • B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
  • C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
  • D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.
Correct Answer: D

Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely causing the lower urine output. The man urinating prior to his arrival to the ED is unlikely; the fall and hip injury would make his ability to urinate difficult. No assessment information indicates he has a head injury or heart failure.

You may also like to solve these questions

The nurse is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance would a positive Chvostek's sign indicate?

  • A. Hypermagnesemia
  • B. Hyponatremia
  • C. Hypocalcemia
  • D. Hyperkalemia
Correct Answer: C

Rationale: You can induce Chvostek's sign by tapping the patient's facial nerve adjacent to the ear. A brief contraction of the upper lip, nose, or side of the face indicates Chvostek's sign. Both hypomagnesemia and hypocalcemia may be tested using the Chvostek's sign, but hypocalcemia is the primary electrolyte imbalance associated with this sign.

You are caring for a patient with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis?

  • A. Hypertension
  • B. Kussmaul respirations
  • C. Increased DTRs
  • D. Shallow respirations
Correct Answer: D

Rationale: If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also renal failure. This type of patient is associated with decreased DTRs, not increased DTRs.

You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

  • A. Overhydration is common among healthy older adults.
  • B. Dehydration causes the skin to appear spongy.
  • C. Inelastic skin turgor is a normal part of aging.
  • D. Skin turgor cannot be assessed in patients over 70.
Correct Answer: C

Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy.

When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?

  • A. Active transport of hydrogen ions across the capillary walls
  • B. Pressure of the blood in the renal capillaries
  • C. Action of the dissolved particles contained in a unit of blood
  • D. Hydrostatic pressure resulting from the pumping action of the heart
Correct Answer: D

Rationale: An example of filtration is the passage of water and electrolytes from the arterial capillary bed to the interstitial fluid; in this instance, the hydrostatic pressure results from the pumping action of the heart. Active transport does not move water and electrolytes from the arterial capillary bed to the interstitial fluid, filtration does. The number of dissolved particles in a unit of blood flow is concerned with osmolality. The pressure in the renal capillaries causes increased filtration.

The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?

  • A. Cimetidine
  • B. Maalox
  • C. Potassium chloride elixir
  • D. Furosemide
Correct Answer: A

Rationale: H2 receptor antagonists, such as cimetidine (Tagamet), reduce the production of gastric HCl, thereby decreasing the metabolic alkalosis associated with gastric suction. Maalox is an oral simethicone used to break up gas in the GI system and would be of no benefit in treating a patient in metabolic alkalosis. KCl would only be given if the patient were hypokalemic, which is not stated in the scenario. Furosemide (Lasix) would only be given if the patient were fluid overloaded, which is not stated in the scenario.

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