Nokea
A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:
- A. fluid volume excess.
- B. hyperkalemia.
- C. hypercalcemia.
- D. fluid volume deficit.
Correct Answer: D
Rationale: Elevated urine osmolarity indicates that the urine is concentrated, suggesting the body is trying to conserve water. This commonly occurs in conditions like dehydration or fluid volume deficit. Assessing the client for fluid volume excess, hyperkalemia, or hypercalcemia would not be the priority in this situation. Therefore, the correct answer is to assess the client for fluid volume deficit. Fluid volume excess is characterized by decreased urine osmolarity, while hyperkalemia and hypercalcemia are related to electrolyte imbalances and would not directly cause elevated urine osmolarity.
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A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
- A. temperature of 102°F and a productive cough
- B. arterial blood gases (ABGs) with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg
- C. trachea deviating to the right
- D. barrel-chested appearance
Correct Answer: C
Rationale: The correct answer is 'trachea deviating to the right.' A mediastinal shift is indicative of a tension pneumothorax, which is a dangerous complication seen in trauma patients with symptoms like crepitus, decreased breath sounds, shortness of breath, and tachypnea. Assessing for acute traumatic injuries is crucial in this context. Choice A, a temperature of 102°F and a productive cough, is common in pneumonia cases and not as concerning as a mediastinal shift. Choice B, ABGs with a PaO2 of 92 mmHg and PaCO2 of 40 mmHg, shows values within normal limits and does not suggest a tension pneumothorax. Choice D, a barrel-chested appearance, is typical of COPD and not directly related to the acute traumatic injury described. A tension pneumothorax is a medical emergency where air cannot escape the pleural cavity, leading to lung collapse and a mediastinal shift to the unaffected side with a downward displacement of the diaphragm.
The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?
- A. Hypocalcemia.
- B. Hyponatremia.
- C. Hyperkalemia.
- D. Hypophosphatemia.
Correct Answer: A.
Rationale: The correct answer is Hypocalcemia. In hypoparathyroidism, where the parathyroid glands are not producing sufficient parathyroid hormone, calcium levels become inadequate. This leads to hypocalcemia, characterized by symptoms such as muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia are not typically associated with hypoparathyroidism. While hyperphosphatemia can be seen in hypoparathyroidism due to decreasing calcium levels, the question specifically asks about the primary electrolyte imbalance closely related to hypoparathyroidism, which is hypocalcemia.
How can a diet high in fiber content benefit an individual?
- A. aid in rapid weight loss.
- B. reduce diabetic ketoacidosis.
- C. lower cholesterol.
- D. reduce the requirement for folate.
Correct Answer: C
Rationale: A diet high in fiber content can help lower cholesterol levels. Fiber-rich foods such as grains, apples, potatoes, and beans are known to aid in reducing cholesterol by binding to cholesterol in the digestive system and preventing its absorption into the bloodstream. Choice A is incorrect as the question does not specify losing weight rapidly but rather focuses on the benefits of a high-fiber diet, which includes aiding in weight management through promoting satiety and regulating digestion. Choice B is incorrect because while fiber helps manage blood sugar levels, it is not directly related to reducing diabetic ketoacidosis, a serious complication of diabetes. Choice D is incorrect as a high-fiber diet does not reduce the need for folate; however, it can aid in the absorption of folate and other essential nutrients.
Teaching about the need to avoid foods high in potassium is most important for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileostomy
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. High potassium levels can further burden the kidneys and worsen the condition. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk for hypokalemia, which is low potassium levels. Therefore, these clients should actually be encouraged to eat foods high in potassium to maintain adequate levels and prevent complications associated with hypokalemia.
A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?
- A. Increase in subcutaneous fat.
- B. Diminished cough reflex.
- C. Long-term memory loss.
- D. Myopia.
Correct Answer: B
Rationale: The correct answer is 'Diminished cough reflex.' Diminished cough reflex is a physical finding consistent with normal aging in older adults, which can increase the risk of aspiration and atelectasis. An increase in subcutaneous fat actually raises the risk of pressure ulcers. While long-term memory is typically preserved in aging unless affected by dementia, short-term memory often declines. Myopia (near-sightedness) is common in younger individuals, but presbyopia (far-sightedness) is more common with aging. Additionally, individuals with myopia may experience an improvement in vision as they age.