Patho practice 4

The nurse is taking the male client's medication history. The client informs the nurse he takes megadoses of vitamin C daily, a daily aspirin, and an iron tablet. Which statement is the nurse's best response?

"Taking aspirin and megadoses of vitamin C may cause crystals in your urine."

The nurse plans care for a client with a serum potassium level of 3.0 mEq/L. The care should include which treatments?

A maximal safe rate of intravenous potassium replacement is 20 mEq/hr. A potassium level of 3.0 is hypokalemia. Administering insulin and cation exchange resin (which is not given in units) would cause the potassium to lower even further; in fact, these treatments are contraindicated for hypokalemia. Sodium would not help with hypokalemia.

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

A newborn is about 70% to 80% TBW by weight. Healthy men have a greater percentage of body water than do healthy women. The percentage of TBW by weight decreases with aging. Most of a person's daily intake of fluid is from water obtained by drinking, not from water derived from oxidative metabolism. Obese individuals have a lower percentage of TBW by weight because adipose tissue is hydrophobic (water-repelling).

A client's serum sodium level is 150 mEq/L. The nurse expects which changes in the client's serum chloride and bicarbonate levels? Select all that apply.

A serum sodium level greater than 145 mEq/L is hypernatremia. Increased serum chloride levels (greater than 105 mEq/L) and decreased serum bicarbonate levels (less than 24 mEq/L) occur in clients with hypernatremia. Chloride changes follow a direct relationship to changes in serum sodium. Bicarbonate levels are decreased in this situation, especially if the client is experiencing metabolic acidosis. Normal serum chloride is 103 mEq/L. Normal serum bicarbonate is 24 mEq/L

A nurse is describing various types of tissue to a client. The nurse should include which type of tissue that stores fat cells?

Adipose tissue stores fat cells; each cell contains a large droplet of fat. Areolar, or loose, tissue has mostly collagenous fibers that are unorganized, with spaces between the fibers. Elastic tissue contains elastic fibers, some collagenous fibers, and fibroblasts. Cartilage is collagenous fibers embedded in a firm matrix.

Which information from the client indicates teaching by the nurse was successful for the actions of aldosterone in regulating water and electrolyte balance? Select all that apply.

Aldosterone is secreted when circulating blood volume or blood pressure is reduced, potassium is increased, or sodium is decreased. It increases (not decreases) renal reabsorption of sodium and water to increase blood volume, blood pressure, and serum sodium levels. It also increases renal excretion (not reabsorption) of potassium.

Lichenification is best described as:

An excoriation in linear fashion

A nurse is caring for a client with a disease caused by eukaryotes. The nurse is caring for which client?

Animals, plants, protozoa, and fungi are eukaryotes. Prokaryotes include cyanobacteria (blue-green algae), bacteria, and rickettsiae.

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

Ascites is accumulation of fluid in the peritoneal space. Pleural effusion is fluid accumulation in the pleural space. Fluid accumulation in the feet is localized or dependent edema. Pericardial effusion is fluid accumulation within the membrane around the heart.

The client is prescribed folic acid, a vitamin. Which information should the nurse discuss with the client?

Avoid drinking any type of alcoholic beverage.

A nurse is reviewing the electrolyte laboratory results on several clients. What is the nurse checking?

Body fluids are composed of water and electrolytes, which are electrically charged and dissociate into constituent ions when placed in solution. An ion is a charged particle. Glucose is a nonelectrolyte. Filtration is the movement of water and solutes through a membrane because of a greater pushing pressure on one side of the membrane than on the other side. Hydrostatic pressure is the mechanical force of water pushing against cellular membranes.

A client has hyperkalemia. Which body system is the priority for the nurse to monitor?

Bradydysrhythmias and delayed conduction are common in hyperkalemia; severe hyperkalemia can cause ventricular fibrillation or cardiac arrest, making the cardiac system the priority. Lungs and kidneys are usually not affected as severely in hyperkalemia as the heart. Although gastrointestinal signs and symptoms occur, they are not as life-threatening as the events in the cardiac system.

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 imbalances increase normal neuromuscular excitability. Clinical manifestations of hypocalcemia are those of muscle spasms, tingling in the extremities, and hyperactive bowel sounds. Imbalances of sodium, chloride, and potassium would not produce these clinical manifestations.

A nurse's assessment in the middle of a shift reveals various changes from this morning for four clients. Which change should be reported to the client's primary healthcare provider immediately?

Cardiac dysrhythmias from hyperkalemia need rapid attention to prevent potentially life-threatening consequences and are therefore the highest priority for reporting. Bradydysrhythmias and delayed conduction are common in hyperkalemia; severe hyperkalemia can cause ventricular fibrillation or cardiac arrest. Certainly a nurse should report hypocalcemia, hypercalcemia, and hypokalemia, but constipation and abdominal distention are not life-threatening.

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

Central nervous system symptoms are the most serious and are related to alterations in membrane potentials and shrinking of brain cells. Cells burst in hyponatremia, not hypernatremia. There is no overhydration or hypertrophy of the brain stem in hypernatremia.

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

Chloride is the major anion in the extracellular fluid and provides electroneutrality, particularly in relation to sodium. Sodium is the major cation in the extracellular fluid. Potassium is the major cation in the intracellular fluid. Magnesium is also an intracellular cation.

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

Clinical manifestations of dehydration include headache and decreased urine output. Heart rate increases with water deficits. Skin turgor decreases in dehydration. Blood pressure decreases in dehydration from a water deficit.

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

Clinical manifestations of hyponatremia (levels below 135 mEq/L) include confusion, lethargy, coma, and perhaps seizures. Thirst and dry mucous membranes are associated with a water deficit and hypernatremia. Hyperactive bowel sounds and intestinal cramping are signs of hypocalcemia. Neuromuscular irritability and diarrhea occur with hyperkalemia.

"My feet swell if I eat salt," says a client who has chronic compensated heart failure, "so I stopped eating it like my nurse practitioner said, but I don't understand how salt causes swelling." What is the nurse's best response?

Congestive heart failure, renal failure, and cirrhosis of the liver are associated with excessive salt and water retention, which causes plasma volume overload, increased capillary hydrostatic pressure, and edema. Salt does not cause vasodilation. Salt does not bind to blood proteins and change osmotic pressure. Gravity does affect edema, but saying salt is not the problem is inaccurate.

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

Decreased antidiuretic hormone secretion is a cause of diabetes insipidus, which prevents water reabsorption in the kidneys, creating large volumes of dilute urine and leading to hypernatremia. Compulsive water drinking leads to water intoxication and hyponatremia. Excessive dietary potassium would not affect the serum sodium concentration. Oversecretion of aldosterone, not a decrease in aldosterone secretion, causes hypernatremia.

Hyponatremia

Decreased osmotic pressure in ECF compartment causes fluid to enter cells

The nurse assesses a client with diarrhea for clinical manifestations of which acid-base imbalance?

Diarrhea causes metabolic acidosis through bicarbonate excretion. Vomiting can cause metabolic alkalosis. Diarrhea causes a metabolic acid-base imbalance rather than a respiratory one.

Which situation will cause the nurse to closely monitor a client for hypokalemia?

Diarrhea increases the amount of potassium lost in the feces, making one predisposed to hypokalemia. In diabetic ketoacidosis, extracellular hydrogen ions move into the cell in exchange for intracellular potassium, which results in hyperkalemia. Oliguric renal failure decreases potassium excretion and leads to hyperkalemia. Parathyroid hormone regulates changes in calcium concentration, not potassium concentration.

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

Edema is excessive accumulation of fluid within the interstitial spaces. The forces favoring fluid movement from the capillaries or lymphatic channels into the tissues are increased capillary hydrostatic pressure, decreased plasma oncotic pressure, increased capillary membrane permeability, and lymphatic channel obstruction. Increased interstitial hydrostatic pressure would facilitate the inward movement of water from the interstitial space back into the capillary, thus decreasing edema.

A nurse is asked by a coworker where one third of a client's total body water is located. How should the nurse respond?

Extracellular fluid (ECF) is all the fluid outside the cells (about one third of total body water) and is divided into smaller compartments. The two main ECF compartments are the interstitial fluid (the space between cells and outside the blood vessels) and the intravascular fluid (blood plasma). Lymph is a small ECF compartment. Two thirds of the body's water is intracellular.

A client has water excess. Which assessment finding will the nurse expect?

Headache is a common symptom of chronic water accumulation. Water excess usually leads to hyponatremia (decreased serum sodium levels), not hypernatremia. The hematocrit is reduced from the dilutional effect of water excess. Weight gain, not weight loss, is common.

A client has hyperaldosteronism. Which fluid and electrolyte imbalance will the nurse monitor for in this client?

Hyperaldosteronism causes excessive renal retention of sodium and water and excessive potassium excretion, which lead to isotonic fluid excess and hypokalemia. Retention of water and sodium leads to extracellular fluid volume excess, rather than deficit. Excess aldosterone results in hypernatremia, not hyponatremia. Sodium concentration is directly affected by aldosterone, and hyperaldosteronism leads to hypernatremia, not normal serum sodium levels.

Chvostek and Trousseau signs indicate which electrolyte imbalance?

Hypocalcemia

Which electrolyte imbalance is the client experiencing CA 7.5 mEq/dl increased neuromuscular excitability, tingling, muscle spasms, pulse 86, respiratory rate 16

Hypocalcemia is a low blood calcium level (less than 8.5 mg/dl) and causes increased neuromuscular excitability, tingling, and muscle spasms. Vital signs are normal. The potassium level is normal (3.5 to 5.0 mEq/L). Hypercalcemia would be a high blood calcium level (greater than 10 to 12 mg/dl) and would cause other signs and symptoms.

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

Hypokalemia causes a weak, irregular pulse. Hypokalemia causes decreased bowel sounds, not hyperactive bowel sounds. Peaked T waves and elevated serum potassium level occur with hyperkalemia, not hypokalemia.

The nurse is taking the health history. Which factors will increase the client's risk for hypokalemia? Select all that apply.

Hypokalemia is low potassium and is caused by diuretics, diarrhea, alcoholism, and alkalosis. A serum level of 5.2 mEq/L is elevated. An adequate intake of fruits and vegetables will not lead to hypokalemia; an inadequate intake can lead to hypokalemia.

Which assessment findings would the nurse expect to be present in the client with hyponatremia? Select all that apply.

Hyponatremia occurs when the serum sodium level drops below 135 mEq/L. Confusion and muscle weakness occur because of changes in the action potential of neurons and muscles. Depressed reflexes occur in hyponatremia. Hyperreflexia is a manifestation of hypernatremia. Hypochloremia (chloride level less than 97 mEq/L) occurs with hyponatremia. Hyperchloremia (chloride level greater than 105 mEq/L) occurs with hypernatremia.

When considering water balance, which statement is the correct balance?

Hypotonic fluid causes cellular swelling.

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 in the body, the kidneys conserve H+ions to allow acid to accumulate to normal levels. If metabolic acidosis exists in the body, the kidneys do not conserve H+ions; they eliminate them. The lungs control the level of CO2, not the kidneys.

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

Increased osmolality stimulates hypothalamic osmoreceptors. In addition to causing thirst, these osmoreceptors signal the posterior pituitary gland to release antidiuretic hormone. Thirst stimulates water drinking. Salty foods would make the situation worse. Quiet time and oxygen are not needed.

A client has a low protein level. What will the nurse observe upon assessment?

Individuals with low protein levels are unable to maintain a normal oncotic pressure; therefore water is not reabsorbed into the circulation and, instead, causes body edema. Bleeding occurs from lack of platelets or trauma. Vomiting occurs from Infection or inflammation. Cyanosis occurs from lack of oxygen.

Which client is most susceptible to dehydration?

Individuals with more body fat have proportionately less total body water (TBW) and tend to be more susceptible to dehydration. Those that are lean or have little body fat have a higher level of TBW than persons with normal weight or obesity. A person with normal weight has a higher TBW percentage in relation to those with obesity but a lower percentage than a person who is lean.

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

Insulin, aldosterone, epinephrine, and alkalosis facilitate the shift of potassium into cells. Insulin deficiency, aldosterone deficiency, acidosis, cell lysis, and strenuous exercise facilitate the shift of potassium out of cells.

If a client in liver failure has a decreased production of protein, what pathophysiologic process will occur, resulting in edema?

Lost or diminished plasma albumin production (e.g., from liver disease or protein malnutrition) contributes to decreased plasma oncotic pressure, leading to edema. Decreased capillary membrane permeability is not affected by a lack of protein; increased capillary membrane permeability occurs with inflammation and immune responses, leading to edema. Aquaporins are water channel proteins that provide permeability to water located on the cell membrane; therefore, aquaporins are not released. Volatile gases can be eliminated as carbon dioxide and do not relate to loss of protein.

A client has low albumin levels from malnutrition. Which pathophysiologic process will produce the resultant edema?

Lost or diminished plasma albumin production (e.g., from liver disease or protein malnutrition) contributes to decreased plasma oncotic pressure. Any type of venous obstruction will cause hydrostatic pressure to increase, but not from a loss of albumin. Stimulation of baroreceptors causes the release of antidiuretic hormone to stimulate thirst, not edema. Osmoreceptors are activated when there is increased osmolality, not edema.

A patient's ABGs reveal the following findings: pH 7.43 PaO2 110 PaCO2 47 HCO3 30. What should be the nurse's best interpretation?

Metabolic alkalosis compensated by respiratory acidosis.

A client has a serum potassium level of 3.0 mEq/L. Which findings is the nurse most likely to observe upon assessment?

Muscle weakness and cardiac dysrhythmias The normal serum potassium level is 3.5 to 5 mEq/L. Moderate to severe hypokalemia causes muscle weakness and cardiac dysrhythmias. Abdominal cramping, diarrhea, anxiety, irritability, slow pulse, and decreased urine output are signs of hyperkalemia

When a client's body releases natriuretic peptides, which piece of equipment should the nurse obtain to determine a therapeutic effect?

Natriuretic peptides cause vasodilation and increase sodium and water excretion, decreasing blood pressure. Temperature, reflexes, and stools are not affected.

A client weighed 142.4 lb yesterday. The nurse weighs the client today and obtains a weight of 146.8 lb. How many liters of fluid did the client retain?

One liter of water weighs 2.2 lb (1 kg). The client gained 4.4 lb (146.8 - 142.4 = 4.4). A weight of 4.4 lb is equal to 2 liters of water (4.4 ÷ 2.2 = 2). One liter would be if the client only gained 2.2 lb; 4.4 L and 5.4 L are too high.

A nurse is teaching a health class to adults. The nurse should include which information about the composition of proteins?

Proteins are made of amino acids. Glucose is a simple carbohydrate. Lipids contain fatty acids and triglycerides. Chromatin is the substance that gives the nucleus its granular appearance.

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 are clinical manifestations of metabolic acidosis and its respiratory compensation. Slow, shallow breathing, belligerence, hyperexcitability, attention deficit disorder, and numbness and tingling around the mouth are not clinical manifestations of metabolic acidosis and its respiratory compensation. Tremors and elevated blood pressure are not clinical manifestations of metabolic acidosis.

A patient's ABGs reveal the following findings: pH 7.37, PaO2 65, PaCO2 50, HCO3 29. What should be the nurse's best interpretation?

Respiratory acidosis compensated by metabolic alkalosis.

A client's 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?

Respiratory alkalosis Decreases in arterial pH and bicarbonate occur with metabolic acidosis. Metabolic alkalosis occurs if pH and bicarbonate levels are elevated. Respiratory acidosis occurs when pH is decreased and carbon dioxide is elevated, whereas respiratory alkalosis occurs when pH is elevated and carbon dioxide is decreased.

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

Symptoms of dehydration in infants include increased thirst, decreased urine output, decreased body weight, decreased skin elasticity, sunken fontanels, absent tears, dry mucous membranes, increased (not decreased) heart rate, and irritability.

Which term should the nurse use to describe a client's major buffer in the extracellular fluid?

The carbonic acid-bicarbonate buffer pair operates in both the lung and the kidney and is a major extracellular buffer. Proteins are intracellular buffers. Hemoglobin is an intracellular buffer. Phosphate is an important element in the renal buffer system.

Which information from a coworker indicates successful teaching by the nurse for the lipid bilayer portion of the plasma membrane that moves toward water?

The hydrophilic head moves toward water, whereas the hydrophobic tail moves away from water. The tail is nonpolar, making it hydrophobic, and the head is polar, making it hydrophilic.

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

The oliguric phase of renal failure decreases potassium excretion, which causes hyperkalemia. Hypokalemia would not occur in renal failure. Hypocalcemia and hyperphosphatemia occur in clients with chronic renal failure.

A nurse is teaching the staff about the eukaryotic cell. Which area should the nurse identify as the plasmalemma

The outer membrane of the cell can be called the plasmalemma or the plasma membrane. The nucleus is located in the center of the cell. The nucleolus is contained within the nucleus. The cytoplasm is the material that fills the space between the nuclear envelope and the plasma membrane, including the aqueous solution (cytosol) and the organelles that the cytosol surrounds.

A client has metabolic acidosis and is breathing deeply and rapidly. How will the nurse report this finding to the oncoming shift?

The respiratory system's efforts to compensate for the increase in metabolic acids in metabolic acidosis result in what are termed Kussmaul respirations (a form of hyperventilation), which are deep and rapid. Hypochloremia, a low level of serum chloride, usually occurs with hyponatremia or an elevated bicarbonate concentration, as in metabolic alkalosis; it is not a type of breathing pattern. The term isotonic indicates that a solution has the same concentration as normal saline; it does not describe a breathing pattern. Breathing rapidly is hyperventilation, not hypoventilation.

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

There is loss of extracellular fluid volume with isotonic fluid loss, causing weight loss, dryness of skin and mucous membranes, decreased urine output, and symptoms of hypovolemia. Distended neck veins occur in isotonic fluid excess. Moist mucous membranes are normal.

The nurse identifies that a client is experiencing an isotonic fluid loss, based on the presence of which assessment findings? Select all that apply.

There is loss of extracellular fluid volume with weight loss (not weight gain), dryness of the skin and mucous membranes, decreased urine output, and symptoms of hypovolemia. Indicators of hypovolemia include a rapid heart rate, flattened neck veins, and normal or decreased blood pressure. Warm skin is a normal finding.

A client has drainage from an intestinal fistula that is being managed at home while it heals. A home health nurse visits regularly to change the dressing. Today the client is already lying down when the nurse arrives, complaining of feeling "weak and dizzy" when standing up. Supine blood pressure is 92/70, and the heart rate is 78. When the client sits up, the client slumps sideways and is temporarily unresponsive. Systolic blood pressure was 77 before the client fell sideways, and the heart rate was very fast. The client has regained consciousness. What is the most appropriate action by the nurse before contacting the client's primary healthcare provider?

Treatment for water deficit is to give water and stop fluid loss. The client has postural hypotension from hypovolemia. Ankle edema occurs with fluid excess, not deficit. How a client sleeps at night will not help with water deficit. Placing the client in a sitting position will make the problem worse, as seen when the client became unresponsive when sitting up.

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

Water balance is regulated primarily by antidiuretic hormone (also known as vasopressin). Aldosterone is a hormone that regulates sodium. Sodium is the major extracellular ion. Natriuretic peptides are hormones produced by the myocardial atria and cause increased sodium and water excretion, decreasing blood pressure.

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 primarily as a function of osmotic forces. Aquaporins are a family of water channel proteins that provide permeability to water at the capillary membrane. Sodium is the major ECF cation, and potassium is the major ICF cation. Potassium maintains the ICF osmotic balance.

A nurse is talking about action potential and resting membrane potential. Which structures in the client's body is the nurse describing?

When a nerve or muscle cell receives a stimulus that exceeds the membrane threshold value, a rapid change occurs in the resting membrane potential, known as the action potential. Gametes, somatic cells, bones, and teeth do not have an action potential and resting membrane potential. Gametes are sperm and egg cells while all the other body cells are called "somatic cells." Collagen forms cablelike fibers or sheets that provide tensile strength or resistance to longitudinal stress. Elastin is a rubber-like protein fiber most abundant in tissues that must be capable of stretching and recoiling.

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

Wound drainage leads to an isotonic fluid loss. The clinical manifestations of this imbalance include dry mucous membranes and increased heart rate, decreased urine output, and symptoms of hypovolemia. Increased blood pressure, edema formation, and decreased hematocrit are manifestations of isotonic fluid excess. A low serum sodium level would occur in hypotonic fluid imbalance and hyponatremia.

A nurse is teaching the client about the organelle that is responsible for the metabolism of cellular energy. Which organelle is it?

mitochondria

osmosis effect on water

pulls water

hydrostatic pressure effect on water

pushes water