Fluid and Electrolyte Imbalance In Class Assignment
The nurse is instructing a client diagnosed with heart failure about a prescribed sodium-restricted diet. Which client statement indicates that additional teaching is required? "I can use as much salt substitute as I want." "I have to read the labels on foods to find out the sodium content." "I have to limit the intake of food with baking soda or baking powder." ) "I can use spices and lemon juice to add flavor to food when cooking."
Correct! "I can use as much salt substitute as I want." Low-sodium salt substitutes are not really sodium-free; they may contain half as much sodium as regular salt. The client should be instructed to use salt substitutes sparingly because larger amounts often taste bitter instead of salty. Clients should also be instructed to read food labels for the amount of sodium in the food item. Baking soda and baking powder contain sodium, so intake should be limited when on a sodium-restricted diet. In place of salt or salt substitutes, the client should be instructed to use herbs, spices, lemon juice, vinegar, and wine as flavoring when cooking.
The nurse is teaching a group of children and their parents about the prevention of heat-related illness during exercise. Which statement by a parent indicates an appropriate understanding of the preventive techniques taught during the teaching session? "It is important for my child to wear dark clothing while exercising in the heat." "Water is the drink of choice to replenish fluids that are lost during exercise." "My child only needs to hydrate at the end of an exercise session." "I will have my child stop every 15-20 minutes during the activity for fluids."
Correct! "I will have my child stop every 15-20 minutes during the activity for fluids." During activity, stopping for fluids every 15-20 minutes is recommended. Hydration should occur before and during the activity, not just at the end. A combination of water and sports drinks is best to replace fluids during exercise. Light-colored, light-weight clothing is best to wear during exercise activities; wearing of dark colors can increase sweating.
The nurse identifies the diagnosis Risk for Impaired Skin Integrity as applicable for a client diagnosed with heart failure. Which assessment finding supports the use of this diagnosis for the client? +3 pitting edema both feet Heart rate 104 and regular Shortness of breath with ambulation Productive cough
Correct! +3 pitting edema both feet Edema of the feet increases the client's risk for impaired skin integrity. Activity Intolerance would be a diagnosis applicable for shortness of breath with ambulation. Risk for Impaired Gas Exchange would be a diagnosis applicable for a productive cough. Risk for Ineffective Peripheral Tissue Perfusion would be a diagnosis applicable for a heart rate of 104 and regular.
The nurse receives shift report on a pediatric medical-surgical unit. The nurse has been assigned four clients for the shift. Which client does the nurse plan to assessment first based on the increased risk for dehydration? A 4-year-old child with a broken leg A 15-month-old child with tachypnea A 16-year-old child with migraine headaches A 10-year-old child with cellulitis of the left leg
Correct! A 15-month-old child with tachypnea The pediatric client with the greatest risk for dehydration is the client who is under 2 years of age experiencing tachypnea which increases insensible fluid loss. The pediatric client with a chronic or acute condition that does not directly affect the GI or electrolyte system (migraine headache, broken leg, or cellulitis) is at a lower risk than is a toddler with a condition that increases insensible water loss.
What is the principal mineralocorticoid that assists in regulating the body's serum sodium balance? Aldosterone Progesterone Antidiuretic hormone Parathyroid hormone
Correct! Aldosterone Aldosterone is the principal mineralocorticoid that assists in regulating serum sodium balance. It does this by stimulating the kidneys to conserve sodium and to excrete potassium when serum sodium levels fall below normal. Water follows the sodium, and blood volume rises. When extracellular fluid (ECF) osmolality increases, antidiuretic hormone is secreted, leading to additional water reabsorption. The atria detect this rise in ECF volume and secrete atrial natriuretic peptide (ANP) to reverse the aldosterone process and promote sodium and water excretion to return the ECF to balance.
An increase in blood hydrostatic pressure would result in which fluid volume disturbance? Fluid volume excess, because the pressure would force fluid out through the capillary walls and into the interstitial compartment. Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the capillaries. Fluid volume excess, because the pressure would force fluid out through the lymphatic system and into the interstitial compartment. Fluid volume deficit, because the pressure would force fluid out of the interstitial compartment and into the lymphatic system.
Correct! Fluid volume excess, because the pressure would force fluid out through the capillary walls and into the interstitial compartment. When extracellular fluid volume excess occurs, the increased fluid volume in the vascular compartment congests the veins. This leads to an increase in blood hydrostatic pressure. In turn, as the pressure against the sides of the capillaries increases, more fluid enters the interstitial compartment, causing further fluid volume excess.
A client in the emergency department is being admitted with a diagnosis of fluid volume deficit. When preparing to assess this client, on which body system should the nurse focus to determine the cause of the imbalance? Gastrointestinal Cardiovascular Genitourinary Musculoskeletal
Correct! Gastrointestinal The most common cause of fluid volume deficit is excessive loss of gastrointestinal fluids, which can result from vomiting, diarrhea, suctioning, intestinal fistulas, or intestinal drainage. Other causes of fluid losses include chronic abuse of laxatives and/or enemas. The client may demonstrate cardiovascular system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate genitourinary system changes because of the fluid volume deficit; however, this body system does not cause the deficit. The client may demonstrate musculoskeletal system changes because of the fluid volume deficit; however, this body system does not cause the deficit.
The nurse is caring for a client who is receiving intravenous fluids postoperatively following cardiac surgery. The nurse is aware that this client is at risk for fluid volume excess. The family asks why the client is at risk for this condition. Which response by the nurse is the most appropriate? "Fluid volume excess is caused by new onset liver failure caused by the surgery." "Fluid volume excess is caused by the intravenous fluids." "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." "Fluid volume excess is caused by inactivity."
Correct! "Fluid volume excess is common due to increased levels of antidiuretic hormone in response to the stress of surgery." Antidiuretic hormone (ADH) and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. A fluid volume deficit would not occur with the administration of intravenous fluids. Liver failure is not caused by the surgery. Fluid volume excess is not caused by inactivity.
Which of the following statements is correct with regard to hypercalcemia? Correct! Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. Hypercalcemia is often a result of hyperparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. Hypercalcemia is often a result of hypoparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. Hypercalcemia is often a result of hypoparathyroidism, because the decreased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood.
Correct! Hypercalcemia is often a result of hyperparathyroidism, because the increased levels of parathyroid hormone associated with this condition cause an increase in the amount of calcium in the blood. Calcium levels are controlled in part by parathyroid hormone; when levels of this hormone rise, so do serum calcium levels. Hyperparathyroidism is a condition characterized by an overactive parathyroid gland. Excessive activity of this gland leads to the secretion of abnormally high amounts of parathyroid hormone, which in turn may lead to hypercalcemia.
The nurse is planning care for a client admitted to the unit with dehydration. The client's lab values indicate a low level of serum sodium. Based on the assessment finding, the nurse determines an appropriate nursing diagnosis to be electrolyte imbalance. Which medical condition supports this nursing diagnosis? Isotonic dehydration Hydrostatic pressure Hypotonic dehydration Osmotic pressure
Correct! Hypotonic dehydration Hypotonic dehydration occurs when fluid loss is characterized by a proportionately greater loss of sodium than water, causing serum sodium to fall below normal levels. Isotonic dehydration occurs when fluid loss is not balanced by intake, and the losses of water and sodium are in proportion. Hydrostatic pressure occurs when extracellular fluid volume excess occurs; the increased fluid volume in the vascular compartment congests the veins. Osmotic pressure pulls fluid into the capillaries, usually in response to the presence of albumin and other plasma proteins made by the liver.
