Porth Pathophysiology 4e Ch. 8
A client diagnosed with schizophrenia has been admitted to the emergency department (ED) after ingesting more than 2 gallons of water in one sitting. Which of the following pathophysiologic processes may result from the sudden water gain? a) Hypernatremia b) Water movement from the extracellular to the intracellular compartment c) Syndrome of inappropriate secretion of ADH (SIADH) d) Isotonic fluid excess in the extracellular fluid compartment
b) Water movement from the extracellular to the intracellular compartment Excess water ingestion coupled with impaired water excretion (or rapid ingestion at a rate that exceeds renal excretion) in persons with psychogenic polydipsia can lead to water intoxication (hyponatremia). A disproportionate gain of water with no accompanying gain in sodium results in the movement of water from the extracellular to the intracellular compartment. Hyponatremia accompanies this process. Because of the lack of sodium increase, accumulated fluid is hypotonic, not isotonic. SIADH is not a consequence of excess water intake.
The nurse is assessing a client who is experiencing hyperventilation. The nurse is aware that the client is at risk for: a) Increased PCO2 b) Decreased PCO2 c) Increased H2CO3 d) Decreased pH
b) Decreased PCO2 Increased ventilation will result in a decreased blood carbon dioxide (PCO2). A decrease in ventilation results in retention of CO2 and build up of acid with a decrease in pH and an increase in the formation of H2CO3 in the blood.
A client tells the nurse that the client has been taking Alka-Seltzer (bicarbonate-antacid) four times a day for the past 2 weeks for an upset stomach. Upon assessment of the client, the nurse notes hyperactive reflexes , tetany, and mental confusion. Arterial blood gases reveal pH 7.55; serum HCO3 37. The nurse suspects the client may be experiencing: a) Respiratory Acidosis b) Metabolic Alkalosis c) Respiratory Alkalosis d) Metabolic Acidosis
b) Metabolic Alkalosis Metabolic alkalosis is characterized by a serum pH greater than 7.45; serum HCO3 greater than mEq/L; and a base excess greater than 3.0. Transient or acute alkalosis is common during or immediately following excess oral ingestion of bicarbonate antacids. Respiratory acidosis as well as metabolic acidosis would have a decrease in pH. Respiratory alkalosis would have an increase in pH and a HCO3 less than 24 mEq/L.
A client has been admitted for deterioration of her renal function due to chronic renal failure. Her admission K+ level is 7.8 mEq/L. The nurse would expect to see which of the following abnormalities on her telemetry (ECG) strip? Select all that apply. a) Tachycardia (fast rate) with frequent early ventricular beats (PVCs) b) Prolonged PR interval with widening of the QRS complex c) Ventricular fibrillation d) Atrial flutter with a 2:1 conduction ratio
b) Prolonged PR interval with widening of the QRS complex c) Ventricular fibrillation Hyperkalemia decreases membrane excitability, producing a delay in atrial and ventricular depolarization, and it increases the rate of ventricular repolarization. If serum K+ levels continue to rise (above 6 mEq/L), there is a prolongation of the PR interval; widening of the QRS complex with no change in its configuration; and decreased amplitude and widening and eventual disappearance of the P wave. The heart rate may be slow. Ventricular fibrillation and cardiac arrest are terminal events.
A nurse caring for a client with a diagnosis of diabetes insipidus (DI) should prioritize the close monitoring of which of the following electrolyte levels? a) Potassium b) Sodium c) Magnesium d) Calcium
b) Sodium The high water intake and high urine output that characterize diabetes insipidus create a risk of sodium imbalance. DI may present with hypernatremia and dehydration, especially in persons without free access to water, or with damage to the hypothalamic thirst center and altered thirst sensation.
As other mechanisms prepare to respond to a pH imbalance, immediate buffering is a result of increased: a) Intracellular albumin b) Hydrogen/potassium binding c) Sodium/phosphate anion absorption d) Bicarbonate/carbonic acid regulation
d) Bicarbonate/carbonic acid regulation The bicarbonate buffering system, which is the principal ECF buffer, uses H2CO3 as its weak acid and bicarbonate salt such as sodium bicarbonate (NaHCO3) as its weak base. It substitutes the weak H2CO3 for a strong acid such as hydrochloric acid or the weak bicarbonate base for a strong base such as sodium hydroxide. The bicarbonate buffering system is a particularly efficient system because its components can be readily added or removed from the body. Hydrogen and potassium exchange freely across the cell membrane to regulate acid-base balance. Sodium is not part of the buffering system. Intracellular protein is part of the body protein buffer system; albumin is extracellular.
A client develops interstitial edema as a result of decreased: a) Vascular volume b) Hydrostatic pressure c) Capillary permeability d) Colloidal osmotic pressure
d) Colloidal osmotic pressure Edema can be defined as palpable swelling produced by an increased interstitial fluid volume. The physiologic mechanisms that contribute to edema formation include factors that (1) increase capillary filtration (hydrostatic) pressure, (2) decrease the capillary colloid osmotic pressure, (3) increase capillary permeability, or (4) produce obstruction to lymph flow.
Magnesium is important for the overall function of the body because of its direct role in: a) Cell membrane permeability b) Somatic cell growth control c) Sodium and tonicity regulation d) DNA replication and transcription
d) DNA replication and transcription Magnesium is essential to all reactions that require ATP, for every step related to replication and transcription of DNA, and for translation of messenger RNA. Magnesium does not have a direct role in controlling the growth of cells, extracellular tonicity and sodium balance, or permeability of the cell surface.
The nurse is assessing a client with hyperkalemia. The nurse is aware that the organ at most risk for this client would be the: a) Liver b) Lungs c) Brain d) Heart
d) Heart The most serious effect of hyperkalemia is on the heart. Hyperkalemia decreases membrane excitability, producing a delay in atrial and ventricular depolarization, and it increases the rate of ventricular repolarization. The brain is at risk for alterations in sodium. The liver and lungs are at risk with hypokalemia.
A client is brought to the emergency department semicomatose and a blood glucose reading of 673. He is diagnosed with diabetic ketoacidosis (DKA). Blood gas results are as follows: serum pH 7.29 and HCO3- level 19 mEq/dL; PCO2 level 32 mm Hg. The nurse should anticipate that which of the following orders may correct this diabetic ketosis? a) Administration of potassium chloride b) Initiating an insulin IV infusion along with fluid replacement c) Administering supplemental oxygen and rebreathing from a paper bag d) Instituting a cough and deep breathing schedule for every hour while awake to improve ventilation
The treatment of metabolic acidosis focuses on correcting the condition that is causing the disorder and restoring the fluids and electrolytes that have been lost from the body. For example, insulin administration and fluid replacement are frequently sufficient to correct a low pH in persons with diabetic ketosis. Administration of potassium chloride is used as a treatment of metabolic alkalosis. Administering supplemental oxygen and rebreathing from a paper bag are usual treatment of respiratory alkalosis. Instituting a cough and deep breathing schedule for every hour while awake to improve ventilation is usual treatment of respiratory acidosis.
The nurse is caring for the following group of clients. Select the client most likely to be diagnosed with respiratory alkalosis. a) 26 yo female w/ anxiety who has been hyperventilating b) 18 yo female who has overdosed on narcotics c) 63 yo male w/ a 40-year history of smoking and chronic lung disease d) 45 yo male w/ pneomothorax after a car accident
a) 26 yo female w/ anxiety who has been hyperventilating Respiratory alkalosis can occur with hyperventilating and the loss of CO2. The other three clients are more at risk for respiratory acidosis as a result of retaining CO2.
The nurse has just received the lab results of a client's calcium level. The nurse identifies a normal calcium level as: a) 9.0 to 10.5 mg/dL b) 3.5 to 5.3 mg/dL c) 13.5 to 14.5 mg/dL d) 12.0 to 15.0 mg/dL
a) 9.0 to 10.5 mg/dL The normal range for calcium is 9.0 to 10.5 mg/dL. A decreased level of calcium is 3.5 to 5.3 mg/dL. Elevated levels of calcium include 12.0 to 15.0 mg/dL and 13.5 to 14.5 mg/dL.
Of the following clients, which would be at highest risk for developing hyperkalemia? a) A male admitted for acute renal failure following a drug overdose b) A client diagnosed with an ischemic stroke with multiple sensory and motor deficits c) An elderly client experiencing severe vomiting and diarrhea as a result of influenza d) A postsurgical client whose thyroidectomy resulted in the loss of some of the parathyroid glands
a) A male admitted for acute renal failure following a drug overdose There are three main causes of hyperkalemia: (1) decreased renal elimination; (2) a shift in potassium from the ICF to ECF compartment; and (3) excessively rapid rate of administration. The most common cause of serum potassium excess is decreased renal function. Stroke does not typically have a direct influence on potassium levels, whereas vomiting and diarrhea can precipitate hypokalemia. Loss of the parathyroid influences calcium, not potassium, levels.
Which of the following scenarios place the client at a high risk for developing hypoparathyroidism and require close supervision for assessing for development of muscle cramps, carpopedal spasm, convulsions, and paresthesia in the hands and feet? Select all that apply. a) A neck cancer client returning from OR after having a radical neck dissection b) A hyperthyroid client experiencing a "thyroid storm" requiring urgent thyroidectomy c) A client with seizure experiencing some anoxic deficits and memory loss d) A client with a history of human papillomavirus (HPV) in the uvula
a) A neck cancer client returning from OR after having a radical neck dissection b) A hyperthyroid client experiencing a "thyroid storm" requiring urgent thyroidectomy Hypoparathyroidism reflects deficient PTH secretion, resulting in low serum levels of ionized calcium. PTH deficiency may occur because of a congenital absence of all of the parathyroid glands or because of an acquired disorder due to inadvertent removal or irreversible damage to the glands during thyroidectomy, parathyroidectomy, or radical neck dissection for cancer. Seizures or history of HPV is not associated with this disorder.
A client with a diagnosis of liver cirrhosis secondary to alcohol abuse has a distended abdomen as a result of fluid accumulation in his peritoneal cavity (ascites). Which of the following pathophysiologic processes contributes to this third spacing? a) Abnormal increase in transcellular fluid volume b) Increased capillary colloidal osmotic pressure c) Polydipsia d) Impaired hormonal control of fluid volume
a) Abnormal increase in transcellular fluid volume Third spacing represents the loss or trapping of extracellular fluid (ECF) in the transcellular space and a consequent increase in transcellular fluid volume. The serous cavities are part of the transcellular compartment located in strategic body areas where there is continual movement of body structures—the pericardial sac, the peritoneal cavity, and the pleural cavity. Polydipsia and increased fluid intake alone are insufficient to cause third spacing, and increased capillary colloidal osmotic pressure would result in increased intracellular fluid (ICF). The etiology of third spacing does not normally include alterations in hormonal control of fluid balance.
A very ill client has been admitted to the hospital for testing for possible septic shock. The client reports light-headedness, dizziness, and tingling/numbness of the fingers and toes. The nurse understands that this is likely due to which physiological phenomenon? a) Decrease in cerebral blood flow b) Impaired alveolar ventilation c) Gain in bicarbonate d) Inability of the kidney to excrete the body's fixed acids
a) Decrease in cerebral blood flow The sign/symptoms of respiratory alkalosis are associated with hyperexcitability of the nervous system and a decrease in cerebral blood flow. A decrease in the CO2 content of the blood causes constriction of cerebral blood vessels. CO2 crosses the blood-brain barrier rather quickly; the manifestations of acute respiratory alkalosis are usually of sudden onset. The person often experiences light-headedness, dizziness, tingling, and numbness of the fingers and toes. Impaired alveolar ventilation is associated with respiratory acidosis. A gain in bicarbonate is associated with metabolic alkalosis. Inability of the kidney to excrete the body's fixed acids occurs with metabolic acidosis.
A client who experienced a traumatic head injury reports extreme thirst. The nurse notes that the client is consuming 10 to 15 L of ice water daily and is experiencing polyuria. Which does the nurse suspect? a) Diabetes Insipidus (DI) b) Syndrome of inappropriate antidiuretic hormone (SIADH) c) Psychogenic Polydipsia d) Diabetes Mellitus
a) Diabetes Insipidus (DI) Diabetes Insipidus is caused by a deficiency or decreased responses to ADH. Persons with DI are unable to concentrate their urine during periods of water restriction, and they excrete large volumes of urine - 3 to 20 L/day. The large output is accompanied by extreme thirst. Temporary neurogenic DI can result from traumatic head injury. SIADH refers to marked retention of fluid. Psychogenic polydipsia is usually seen in clients with psychiatric disorders, commonly schizophrenia. Diabetes Mellitus refers to an elevated glucose level noted in untreated/undiagnosed diabetes mellitus.
An elderly client is admitted with elevated magnesium level related to a history of renal insufficiency and excess use of antacids and laxatives containing magnesium. On admission assessment, the nurse notes which clinical manifestations that correlate to hypermagnesemia? Select all that apply. a) Hyporeflexia b) Blood pressure 180/90 c) Tetanic muscle contractions d) Muscle weakness causing shallow breathing e) Paresthesia of the lips
a) Hyporeflexia d) Muscle weakness causing shallow breathing The signs and symptoms occur only when serum magnesium levels exceed 4.0 mg/dL. Hypermagnesemia affects neuromuscular and cardiovascular function. Increased levels of magnesium cause hyporeflexia and muscle weakness. Blood pressure is decreased, and the ECG shows an increase in the PR interval, a shortening of the QT interval, T-wave abnormalities, and prolongation of the QRS and PR intervals. Severe hypermagnesemia is associated with muscle and respiratory paralysis, complete heart block, and cardiac arrest. Signs of magnesium deficiency are not usually apparent until the serum magnesium is less than 1.0 mEq/L. Hypomagnesemia is characterized by an increase in neuromuscular excitability as evidenced by hyperactive deep tendon reflexes, paresthesias (i.e., numbness, pricking, tingling sensation), muscle fasciculations, and tetanic muscle contractions.
A client has received too much morphine (narcotic) in the postsurgical recovery room. Blood gas results reveal the patient has developed respiratory acidosis. Which of the following assessment findings correlate with acute primary respiratory acidosis? Select all that apply. a) Irritability b) Tingling/numbness in the fingers and toes c) Muscle twitching d) Respiratory depression e) Cardiac palpitations
a) Irritability c) Muscle twitching d) Respiratory depression The signs and symptoms of respiratory acidosis depend on the rapidity of onset and whether the condition is acute or chronic. Elevated levels of CO2 produce vasodilation of cerebral blood vessels, causing headache, blurred vision, irritability, muscle twitching, and psychological disturbances. If severe and prolonged, it can cause an increase in CSF pressure and papilledema. Impaired consciousness, ranging from lethargy to coma, develops as the PCO2 rises to extreme levels. Paralysis of extremities may occur, and there may be respiratory depression. Respiratory alkalosis is associated with light-headedness, dizziness, tingling, and numbness of the fingers and toes. These manifestations may be accompanied by sweating, palpitations, panic, air hunger, and dyspnea.
A client with a history of heart and kidney failure is brought to the emergency department. Upon assessment/diagnosis, it is determined the client is in decompensated heart failure. Of the following assessment findings, which are associated with excess intracellular water? Select all that apply. a) Lethargy b) Confusion c) Hyperactive deep tendon reflexes d) Seizures e) Firm, rubbery tissue when palpating lower extremities
a) Lethargy b) Confusion d) Seizures Hyponatremia is usually defined as a serum sodium concentration of less than 135 mEq/L. Muscle cramps, weakness, and fatigue reflect the effects of hyponatremia on skeletal muscle function and are often early signs of hyponatremia. The cells of the brain and nervous system are the most seriously affected by increases in intracellular water. Symptoms include apathy, lethargy, and headache, which can progress to disorientation, confusion, gross motor weakness, and depression of deep tendon reflexes. Seizures and coma occur when serum sodium levels reach extremely low levels. Hypovolemia, third spacing (maldistribution of body fluid), and dehydration are associated with hypernatremia and/or hypertonicity.
Arterial blood gases of a client with a diagnosis of acute renal failure reveal a pH of 7.25, HCO3- level of 21 mEq/L, and decreased PCO2 level accompanied by a respiratory rate of 32. This client is most likely experiencing which disorder of acid-base balance? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis
a) Metabolic acidosis Metabolic acidosis involves a decreased serum HCO3- concentration along with a decrease in pH. In metabolic acidosis, the body compensates for the decrease in pH by increasing the respiratory rate in an effort to decrease PCO2 and H2CO3 levels.
The nurse is assessing a client for early manifestations of hyponatremia. The nurse would assess the client for: a) Muscle Weakness b) Dry, sticky mucous membranes c) Peaked T Wave on EKG d) Tachycardia
a) Muscle Weakness Muscle cramps, weakness, and fatigue reflect the effects of hyponatremia on skeletal muscle function and are often early signs of hyponatremia. Dry, sticky mucous membranes as well as tachycardia reflect hypernatremia. A peaked T wave on the EKG reflects hyperkalemia.
The nurse is caring for a client who is experiencing an increased level of aldosterone secretion. The nurse anticipates that the client may develop: a) Sodium and water retention b) water and potassium retention c) potassium retention and water excretion d) potassium and sodium excretion
a) Sodium and water retention Aldosterone acts at the level of the cortical collecting tubules of the kidneys to increase sodium reabsorption and water retention while increasing potassium elimination. Potassium retention and water excretion as well as potassium and sodium excretion refer to a decreased level of aldosterone.
The nurse is caring for a client with isotonic fluid volume deficit. The nurse would anticipate the client to manifest: Select all that apply. a) hypotension b) tachycardia and weak pulse c) increased hematocrit and BUN d) weight gain e) decreased body temperature f) decreased urine output
a) hypotension b) tachycardia and weak pulse c) increased hematocrit and BUN f) decreased urine output Isotonic fluid volume deficit results when water and electrolytes are lost in isotonic proportions. It is almost always caused by a loss of body fluids and is often accompanied by a decrease in fluid intake. The manifestations reflect a decrease in extracellular fluid and include thirst, loss of body weight, decreased output, impaired temperature regulation, concentration of blood cells, and BUN, and a decrease in arterial and venous volumes. Impaired temperature regulation reflects fluid volume deficit.
A heart failure client has gotten confused and took too many of his "water pills" (diuretics). On admission, his serum potassium level was 2.6 mEq/L. Of the following assessments, which correlate to this hypokalemia finding? Select all that apply. a) polyuria b) constipation c) bradycardia d) paresthesia with numbness of the lips/mouth e) ECG showing short runs of ventricular fibrillation
a) polyuria b) constipation d) paresthesia with numbness of the lips/mouth The manifestations of hypokalemia include alterations in neuromuscular, gastrointestinal, renal, and cardiovascular function. There are numerous signs and symptoms associated with gastrointestinal function, including anorexia, nausea, and vomiting. Atony of the gastrointestinal smooth muscle can cause constipation, abdominal distention, and, in severe hypokalemia, paralytic ileus. Urine output and plasma osmolality are increased; urine specific gravity is decreased; and complaints of polyuria, nocturia, and thirst are common. The most serious effects of hypokalemia are on the heart. The first symptom associated with hyperkalemia typically is paresthesia (a feeling of numbness and tingling). Hyperkalemia results in prolongation of the PR interval; widening of the QRS complex with no change in its configuration; and decreased amplitude, widening, and eventual disappearance of the P wave. The heart rate may be slow. Ventricular fibrillation and cardiac arrest are terminal events.
The nurse is assessing a client with fluid volume excess. The nurse anticipates the client would manifest: a) weight gain b) decreased blood pressure c) increased BUN d) weak, rapid pulse
a) weight gain Isotonic fluid volume excess is manifested by an increase in interstitial and vascular fluids and is characterized by weight gain over a short period of time.
The nurse is aware that the major role of the kidneys in regulating acid-base balance is to increase the production of: a)HCO3 - b)HCl c)H2CO3 d)H+
a)HCO3 - The kidneys play a critical role in maintaining acid-base balance. They accomplish this through the reabsorption of HCO3-, regulation of H+ secretion, and generation of new HCO3-. The hydrogen/bicarbonate exchange system regulates pH through the secretion of excess H+ and reabsorption of HCO3- by the renal tubules. Bicarbonate is freely filtered in the glomerulus and reabsorbed or reclaimed in the tubules. Each HCO3- that is reclaimed requires the secretion of an H+. H2CO3 is a weak acid. HCl is found in gastric fluid. The kidneys would eliminate, not increase, production of H ion.
The physician has ordered an anion gap as a laboratory test for a client experiencing metabolic acidosis. The nurse recognizes that the test will measure: a) ratio of hydrochloric acid and bicarbonate b) phosphates, sulfates, and proteins c) chloride and bicarbonate d) base excess or deficit
b) phosphates, sulfates, and proteins The anion gap describes the difference between the serum concentration of the major measured cation (Na+) and the sum of the measured anions (Cl- and HCO3-). This difference represents the concentration of unmeasured anions, such as phosphates, sulfates, organic acids, and proteins.
The nurse would anticipate the laboratory results of a client experiencing metabolic acidosis to include: a) pH of 7.35 and HCO3 of 22 mEq/L b)pH of 7.25 and HCO3 of 18 mEg/L c) pH of 7.45 and HCO3 of 24 mEg/L d) pH of 7.50 and HCO3 of 45 mEq/L
b)pH of 7.25 and HCO3 of 18 mEg/L A diagnosis of metabolic acidosis is made on the basis of decreased pH and HCO3 levels. A pH of 7.25 is well below the reference range of 7.35-7.45 and an HCO3 level of 18 mEq/L is below the reference range of 22-26 mEq/L. A pH level that is above the reference range suggests alkalosis, not acidosis.
Hypoparathyroidism causes hypocalcemia by: a) Increasing serum magnesium b) Increasing phosphate excretion c) Blocking release of calcium from bone d) Blocking action of intestinal vitamin D
c) Blocking release of calcium from bone The most common causes of hypocalcemia are abnormal losses of calcium by the kidney, impaired ability to mobilize calcium from bone due to hypoparathyroidism, and increased protein binding or chelation such that greater proportions of calcium are in the nonionized form. Magnesium deficiency inhibits PTH release and impairs PTH action on bone resorption. Phosphate and calcium are inversely related, and PTH does not control phosphate excretion. PTH does not exert control of vitamin D action in the intestine, but elevated vitamin D levels can suppress PTH release.
Which of the following assessments should be prioritized in the care of a client who is being treated for a serum potassium level of 2.7 mEq/L? a) Detailed fluid balance monitoring checking for pitting edema b) Arterial blood gases looking for respiratory alkalosis c) Cardiac monitoring looking for prolonged PR interval and flattening of the T wave d) Monitoring of hemoglobin levels and oxygen saturation
c) Cardiac monitoring looking for prolonged PR interval and flattening of the T wave The most serious effects of hypokalemia are on the heart, a fact that necessitates frequent electrocardiography or cardiac telemetry. Hypokalemia produces a decrease in the resting membrane potential, causing prolongation of the PR interval. It also prolongs the rate of ventricular repolarization, causing depression of the ST segment, flattening of the T wave, and appearance of a prominent U wave. This supersedes the importance of fluid balance monitoring, arterial blood gases, oxygen saturation, or hemoglobin levels.
The nurse is reviewing the following lab results of a client diagnosed with renal failure: pH: 7.24 PCO2: 38 mm Hg HCO3: 18 mEq/L The nurse would interpret this as: a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic acidosis d) Metabolic alkalosis
c) Metabolic acidosis Metabolic acidosis would be diagnosed based on the findings related to a low pH level (<7.3) and a low bicarbonate level. Respiratory acidosis represents a decreased pH and an increased PCO2, metabolic alkalosis represents an increased pH and an increased HCO3, and respiratory alkalosis represents an increased pH and a decreeased PCO2)
A 2-week-old infant (full-term at birth) is admitted to the pediatrics unit with "spitting up large amounts of formula" and diarrhea. The infant has developed a weak suck reflex. Which of the following statements about total body water (TBW) is accurate in this situation? a) About 52% of the infants' weight accounts for the amount of water in their body. b) Because of the infants' higher fat ratio, one should anticipate an increased TBW to as high as 90%. c) Most full-term infants have a TBW of approximately 75% due to their high metabolic rate. d) Most of an infant's TBW remains in the ICF compartment, so they should be able to transfer needed water into the ECF space.
c) Most full-term infants have a TBW of approximately 75% due to their high metabolic rate. Infants normally have more TBW than older children or adults. TBW constitutes approximately 75% to 80% of body weight in full-term infants and an even greater percentage in premature infants. In males, the TBW decreases in the elderly population to approximately 52% TBW. Obesity decreases TBW, with levels as low as 30% to 40% of body weight in adults. Infants have more than half of their TBW in their ECF compartment, as compared to adults.
The most reliable method for measuring body water or fluid volume increase is by assessing: a) tissue turgor b) intake and output c) body weight change d) serum sodium levels
c) body weight change Daily weights are a reliable index of water volume gain (1 L of water weighs 2.2 pounds). Daily weight measurements taken at the same time each day with the same amount of clothing provide a useful index of water gain due to edema. When an unbalanced distribution of body water exists in the tissues and organs, assessment of surface skin tissue turgor will be inaccurate. Measurement of renal output is unreliable because fluid retention may be a compensatory response, or the renal system may be dysfunctional. Serum sodium levels are affected by multiple variables other than body water volume.
During the assessment of a client with heart failure, the nurse uses finger pressure to determine if edema is present in the lower extremities. When would the nurse document pitting edema? a) indentation is not present b) the area is firm and discolored c) indentation remains after the finger has been removed. d) the skin is thickened and hard.
c) indentation remains after the finger has been removed. If an indentation remains after the finger has been removed, pitting edema is identified. It is evaluated on a scale of +1(minimal) to +4(severe). When the area is firm and discolored, peripheral vascular insufficiency is indicated. Thickened and hard skin refers to lymphedema, and no identation refers to normal.
Water movement from the side of the membrane having a lesser number of particles and greater concentration of water to the side having a greater number of particles and lesser concentration of water is termed: a) active transport b) diffusion c) osmosis d) filtration
c) osmosis Osmosis is the force that moves water from the side of the membrane having a lesser number of particles and greater concentration of water to the side having a greater number of particles and lesser concentration of water. Active transport is the movement of ions against an electrical or chemical gradient. Diffusion is the process by which particles in solution move from an area of higher concentration to lower, resulting in equal distribution. Filtration is the process of passing a liquid though a filter that is accomplished by gravity, vacuum, or pressure.
The nurse is reviewing a client's arterial blood gas (ABG) results. The nurse interprets the client's pH level as normal when the results identify a: a) pH of 7.55 to 7.8 b) pH of 7.00 to 7.25 c) pH of 7.35 to 7.45 d) pH of 6.55 to 7.12
c) pH of 7.35 to 7.45 A normal pH level ranges from 7.35 to 7.45. pH of 6.55 to 7.12 and 7.00 to 7.25 represent acidotic states. pH f 7.55 to 7.8 represents an alkalotic state.
The nurse is assessing a client who has developed hypocalcemia. The nurse anticipates the assessment data to include: Select all that apply. a) signs of kidney stones b) negative Trousseau sign c) serum calcium less than 8.5mg/dL d) tetany e) lethargy f) bone pain
c) serum calcium less than 8.5mg/dL d) tetany f) bone pain Calcium is important for neuronal excitability; it is necessary for skeletal, cardiac, and smooth muscle contraction. Nerves exposed to low levels of ionized calcium show decreased thresholds for excitation, repetitive responses to a single activity and, in extreme cases, continuous activity. Manifestations can include paresthesia, tetany, spasms, seizures, osteomalacia, bone pain, hypotension, and cardiac effects. Lethargy as well as signs of kidney stones reflect hypercalcemia.
A female client with a history of chronic renal failure has a total serum calcium level of 7.9 mg/dL. While performing an assessment, the nurse should focus on which of the following clinical manifestations associated with this calcium level? a) Complaints of shortness of breath on exertion with decreased oxygen saturation levels b) Difficulty arousing the client and noticing she is disoriented to time and place c) Heart rate of 120 beats/minute associated with diaphoresis (sweaty) d) Intermittent muscle spasms and complaints of numbness around her mouth
d) Intermittent muscle spasms and complaints of numbness around her mouth Spasms and numbness are characteristic of hypocalcemia. Respiratory effects, tachycardia, and diaphoresis are not associated with low calcium levels, whereas decreased level of consciousness can be indicative of hypercalcemia.
The syndrome of inappropriate antidiuretic hormone (SIADH) is characterized by: a) Increased osmolality level of 360 mOsm/kg b) Excessive thirst with fluid intake of 7000 mL/day c) Copious dilute urination with output of 5000 mL/day d) Low serum sodium level of 122 mEq/L
d) Low serum sodium level of 122 mEq/L SIADH results from a failure of the negative feedback system that regulates the release and inhibition of antidiuretic hormone (ADH). ADH secretion continues even when serum osmolality is decreased, causing water retention and dilutional hyponatremia. Diabetes insipidus, deficiency or decreased response to ADH, is characterized by increased serum osmolality, excessive thirst, and polyuria. Urine output decreases in SIADH despite adequate or increased fluid intake.
In isotonic fluid volume deficit, changes in total body water are accompanied by: a) Intravascular hypotonicity b) Increased intravascular water c) Increases in intracellular sodium d) Proportionate losses of sodium
d) Proportionate losses of sodium Isotonic fluid volume deficit causes a proportionate loss of sodium and water. Hypotonicity results from water retention or sodium loss. Increased intravascular water causes sodium to move into the cell excessively.
The health care provider has ordered the administration of a hypertonic intravenous (IV) solution for a client. The nurse anticipates that the IV fluid will cause water to shift how? a) from the transcellular to the intracellular space b) from the intravascular to the interstitial space c) from the interstitial to the transcellular space d) from the intracellular to the intravascular space
d) from the intracellular to the intravascular space Water moves from the side of the membrane having a lesser number of particles and greater concentration of water to the side having a greater number of particles and lesser concentration of water.
A client has been receiving intravenous normal saline at a rate of 125 mL/hour since her surgery 2 days earlier. As a result, she has developed an increase in vascular volume and edema. Which of the following phenomena accounts for this client's edema? a) Obstruction of lymph flow b) increased capillary permeability c) decreased capillary colloidal osmotic pressure d) increased capillary filtration pressure
d) increased capillary filtration pressure An increase in vascular volume results in an increase in capillary filtration pressure. Consequently, movement of vascular fluid into the interstitial spaces increases and edema ensues. An increase in vascular volume does not directly result in obstruction of lymph flow, increased capillary permeability, or decreased capillary colloidal osmotic pressure.
The nurse is reviewing lab results of a client diagnosed with metabolic acidosis. The most important electrolyte for the nurse to assess would be: a) Magnesium (Mg2+) b) Sodium (Na+) c) Calcium (Ca2+) d)Potassium (K+)
d)Potassium (K+) When excess H+ is present in the extracellular fluid (ECF), it moves into the intracellular fluid (ICF) in exchange for K+, and when excess K+ is present in the ECF, it moves in the ICF in exchange for H+. Thus, alterations in potassium levels can affect acid-base levels. Acidosis tends to increase serum potassium levels by causing potassium to move from the ICF to the ECF. A shift in potassium from the ICF into the ECF also can lead to elevated serum potassium levels.
