Patho Evolve Ch. 5

Which clinical condition will cause the nurse to closely monitor a client for hypernatremia?

Decreased antidiretic hormone secretion

A client has ascites. Which area should the nurse assess?

Peritoneal space

A nurse is teaching the staff about the electrolyte that is closely associated with water. Which information from the staff indicates teaching was successful?

Sodium

A nurse is reviewing laboratory results. Which arterial blood pH finding indicates a client has fully compensated metabolic acidosis?

pH 7.4

A nurse weighs a client. Which principle should the nurse remember?

1 liter of water weighs 2.2 lb (1 kg)

Which serum sodium level result will indicate to the nurse that a client has hyponatremia?

135 mEq/L

Which serum sodium level will alert the nurse that the client has hypernatremia?

150mmEq/L

When planning care for a normal adult male client, what percentage of body weight is total body water?

60%

A client has hyperkalemia. Which actions will the nurse take?

Administer glucose, administer calcium gluconate, adminsister sodium bicarbonate, and adminsiter cation exchange resins.

A nurse is talking about vasopressin. What is the nurse describing?

Antidiuretic hormone

The nurse expects a client with a serum level of 129 mEq/L to have which assessment findings?

Confusion and lethargy

The nurse assesses a client with a large draining pressure ulcer for signs of fluid imbalance. Which findings would the nurse expect to find?

Increased heart rate and dry mucous membranes

What are the client's two main extracellular fluid compartments?

Interstitial fluid and intravascular fluid

Which client is most predisposed to hyerphosphatemia?

One with chronic renal failure

A nurse monitors for central nervous system symptoms in a client with hypernatremia. What is the rationale for the nurse's actions?

Shrinking of brain cells results in these symptoms.

Which information from the client indicates that the nurse's teaching about magnesium was successful?

Symptoms of hypomagnesemia include muscle cramps and irritability.

Which fluid will the nurse measure as intake?

Water and other beverages that the client drinks

While the nurse is reviewing arterial blood gas results, which finding would indicate the adult client has a normal arterial blood pH?

7.4

The nurse will monitor which clients for the release of antidiuretic hormone (ADH)

A client with diarrhea. A client with a drop in blood pressure. A client with decreased blood volume. A client with increased plasma osmolality.

Which information indicates the nurse has an accurate understanding of client's total water (TBW)?

A full time newborn infant is about 70% to 80% TBW bby weight. Healthy men have a greater percentage of body water than do healthy women.

Which substances will the nurse include when teaching about the kidney's ability to properly maintain a client's serum pH?

Ammonia, Phosphate, Bicarbonate, and carbonic acid

A client has an edematous leg. Which action should the nurse take?

Apply compression stockings

A hospitalized client complains of tingling in the hands and feet. The nurse assesses hyperactive bowel sounds and muscle spasms of the hands and face. Which serum laboratory value would the nurse check before contacting the primary healthcare provider?

Calcium

A client has a serum potassium level of 3.0 mEq/L. The nurse monitors the client for which assessment findings?

Confusion, decreased bowel sounds and weak, irregular pulse rates.

A client is receiving intravenous magnesium sulfate to prevent seizure. What assessment finding would indicate to the nurse that the infusion rate is too fast?

Diminished deep tendon reflexes

Which assessment findings would the nurse expect to find in a client with isotonic fluid loss?

Dry skin, weight loss and decreased urine output

A client experiencing an isotonic fluid excess would have which clinical manifestations when the nurse performs an assessment?

Edema, weight gain and distended neck veins

Which change in laboratory values will the nurse assess as evidence of renal compensation for a client's respiratory acidosis?

Elevated bicarbonate ion concentration

A client has a significant water deficit. Which assessment findings of dehydration will the nurse observe?

Headache and decreased urine volume

A client has a serum potassium concentration of 5.6 mEq/L. Which term should the nurse use to describe this condition?

Hyperkalemia

A client with oliguria from renal failure should be closely monitored by the nurse for which electrolyte imbalance?

Hyperkalemia

A nurse found during the history that a client has chronically overused magnesium-aluminum antacids for a long period of time. The nurse will expect to find which laboratory result?

Hypophosphatemia

A client has an acid-base imbalance. The nurse would expect the client's renal buffering system to respond in which manner?

If metabolic alkalosis exists, the kidneys conserve H+ ions.

A client is hospitalized with a malignant tumor that causes secretion of parathyroid hormone. What assessment findings will alert the nurse that the client is developing an expected electrolyte imbalance?

Increased serum calcium, lethargy and constipation

Which term should the nurse use to describe the fluid located within the client's cells?

Intracellular

A nurse is assessing an infant who has dehydration. Which assessment findings will support this condition?

Irritability, sunken fontanels, decreased urine output and decreased skin eleasticity.

Which information indicates the nurse has an accurate understanding of hyperchloremia in a client?

Is an elevation of serum chloride concentration above 105 mEq/L

Which information from the nurse indicates a correct understanding of the physiologic factor that has the most impact on the reabsorption of water into the client's capillary space from the interstitial space?

It is capillary oncotic pressure.

A nurse is teaching about the major anion in the extracellular fluid. Which information from the client indicates teaching was successful?

It is chloride

A client is having problems with bicarbonate reabsorption and regeneration. Which acid/base organ should the nurse assess?

Kidneys

When the nurse is taking the client's history, which finding will cause the nurse monitor for signs of hypophosphatemia?

Long-term alcohol abuse

A client has edema. Which pathophysiologic processes should the nurse consider when planning care for this client?

Lymphatic channel obstruction, decreased plasma oncotic pressure, increased capillary hydrostatic pressure, and increased capillary membrane permeability.

A nurse is teaching a client about magnesium. Which information should the nurse include?

Magnesium is mainly stored in the bones. Alcohol-related diseases frequently cause low magnesium levels. Magnesium has an important role in smooth muscle contraction and relaxation.

A client laboratory test results reveal decreased arterial pH and bicarbonate levels. The nurse interprets these results to determine that the client is experiencing which acid-base imbalance?

Metabolic acidosis

A client has respiratory alkalosis and develops carpopedal spasms. What will the nurse observe upon assessment?

Muscle spasms in the fingers and toes

A nurse is caring for an older client and closely monitors for dehydration. What is the rationale for the nurse's action?

Older adults have a reduced ability to regulate sodium and water balance.

A client's osmoreceptors are stimulated. Which action should the nurse take?

Provide a glass of water

A child is diagnosed with starvation ketoacidosis (a metabolic acidosis). What clinical manifestations should the nurse anticipate when assessing the child?

Rapid, deep breathing, lethargy, and abdominal pain

A nurse is asked by a client what regulates potassium levels. How should the nurse respond?

The Kidneys

A child has been vomiting for 2 days. The nurse's assessment of the child finds rapid pulse, dry mouth, decreased skin elasticity, and irritability. How should the nurse interpret these assessment findings?

The child is dehydrated.

A nurse is assessing a client. Which findings will cause a shift of potassium into the client's cells?

The client has alkalosis. The client recieved insulin. Aldosterone is released in the clinet's body. Epinephrine is released in the client's body.

A nurse is caring for clients with edema. Which client conditions can lead to edema formation?

Venous obstruction, increased salt and water retention and decreased serum albumin production

A nurse is teaching the staff about body fluid movement. Which information should the nurse include in the teaching session?

Water moves between ICF and ECF compartments by osmotic forces.

Assessment of the client with hypokalemia would reveal which clinical manifestations?

Weak, irregular pulse