NU 112 Assessment Related To Electrolyte Balance

A patient presents to the emergency department (ED) with a serum phosphate concentration of 3.1 mEq/L. Which should the nurse assess this patient for based on this laboratory value? tetany hyperrefexia muscle cramps

tetany hyperrefexia muscle cramps

The nurse should expect that a patient with a serum potassium concentration of 3.1 mEq/L would have which clinical manifestation? Hyperactive deep tendon reflexes Confusion Decreased bowel sounds Decreased heart rate

Answer: Decreased bowel sounds Explanation: Hyperactive deep tendon reflexes A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. Hyperactive deep tendon reflexes are associated with hypocalcemia and hypomagnesemia, not hypokalemia. Confusion A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. Confusion is a clinical manifestation associated with hyponatremia, hypernatremia, or hypercalcemia, not hypokalemia. Decreased bowel sounds A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. Decreased bowel sounds are associated with hypokalemia because intestinal smooth muscle becomes weak. Decreased heart rate A serum potassium concentration of 3.1 mEq/L indicates hypokalemia. A decreased heart rate, or bradycardia, is a clinical manifestation associated with hyperkalemia, not hypokalemia.

Which test should the nurse anticipate for a patient with hyperkalemia? Urine specific gravity Serum calcium Electrocardiogram Urine osmolality

Answer: Electrocardiogram Explanation: Urine specific gravity Urine specific gravity is a laboratory test used to assess and monitor sodium imbalances, not hyperkalemia. Serum calcium A serum calcium concentration is used to assess and monitor patients who are experiencing a calcium imbalance such as hypocalcemia and hypercalcemia. This laboratory test would not be useful to monitor a patient with hyperkalemia who is experiencing cardiac dysrhythmia. Electrocardiogram An electrocardiogram (ECG) should be anticipated for a patient with hyperkalemia in order to diagnose and monitor cardiac dysrhythmias. Urine osmolality Urine osmolality is a laboratory test that might be used for a patient experiencing sodium imbalances, not hyperkalemia.

The nurse should expect that a patient with severe hypocalcemia would have which clinical manifestation? Stupor Personality changes Laryngospasm Constipation

Answer: Laryngospasm Explanation: Stupor Stupor is a clinical manifestation of hypercalcemia, not hypocalcemia. Personality changes Personality changes are clinical manifestations of hypercalcemia, not hypocalcemia. Laryngospasm Laryngospasm is a clinical manifestation of severe hypocalcemia. Constipation Constipation is a clinical manifestation of hypercalcemia or hypokalemia, not hypocalcemia.

Which assessment finding would support the diagnosis of hypocalcemia? Trousseau sign Lethargy Shallow respirations Stupor

Answer: Trousseau sign Explanation: Trousseau sign Trousseau sign is a neurologic symptom of spasm of the muscles in the hand and wrist that occurs when the blood supply to the hand is occluded with a blood pressure cuff. It indicates increased neuromuscular excitability and is associated with hypocalcemia or hypomagnesemia. Lethargy Lethargy is a clinical manifestation associated with hypercalcemia, not hypocalcemia. Shallow respirations Shallow respirations from muscle weakness are associated with severe hypokalemia, not hypocalcemia. Stupor Stupor is a clinical manifestation associated with hypercalcemia, not hypocalcemia.

Which clinical manifestations should the nurse anticipate when assessing a patient who is diagnosed with hypernatremia? Select all that apply. Hyperactive deep tendon reflexes Confusion Thirst Lethargy Seizures

Answers: Confusion Thirst Lethargy Seizures Explanation: Hyperactive deep tendon reflexes Hyperactive deep tendon reflexes are a clinical manifestation the nurse would anticipate for a patient diagnosed with hypocalcemia or hypomagnesemia, not hypernatremia. Confusion Confusion is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia because osmotic shifts cause brain cells to shrivel. Thirst Thirst is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia. Lethargy Lethargy is a clinical manifestation the nurse would anticipate for a patient diagnosed with hypernatremia. Seizures Seizures are a clinical manifestation the nurse would anticipate for a patient diagnosed with severe hypernatremia.

Which questions should the nurse ask when conducting a health history assessment for a patient who has a potassium imbalance? Select all that apply. "Do you have lactose intolerance?" "Do you take a diuretic, such as furosemide (Lasix)?" "Are you experiencing swelling in your feet?" "Do you use a salt substitute on your food?" "Do you eat canned meats or vegetables often?"

Answers: Do you take a diuretic, such as furosemide (Lasix)?" "Do you use a salt substitute on your food?" Explanation: "Do you have lactose intolerance?" Lactose intolerance would not cause a potassium imbalance. "Do you take a diuretic, such as furosemide (Lasix)?" Furosemide is a potassium-wasting diuretic, which can cause hypokalemia. "Are you experiencing swelling in your feet?" Edema is not a clinical manifestation of potassium imbalance. "Do you use a salt substitute on your food?" Overuse of potassium-rich salt substitutes by people who have poor renal excretion may cause hyperkalemia. "Do you eat canned meats or vegetables often?" Canned meats and vegetables provide a hidden source of sodium not potassium.

The nurse is assessing a patient with hypomagnesemia and anticipates which manifestations? Select all that apply. Diaphoresis Seizures Hypotension Nystagmus

Answers: Seizures Nystagmus Explanation: Diaphoresis Diaphoresis is a clinical manifestation of hypermagnesemia, not hypomagnesemia. Seizures Seizures are a clinical manifestation of hypomagnesemia, which causes increased neuromuscular excitability. Hypotension Hypotension is a clinical manifestation of hypermagnesemia, not hypomagnesemia. Nystagmus Nystagmus is a clinical manifestation of hypomagnesemia, which causes increased neuromuscular excitability.

The nurse is providing care to a patient whose serum potassium level is 5.2 mEq/L. Which clinical manifestation should the nurse monitor the patient for during the assessment? Bradycardia Hyperactive deep tendon reflexes Lethargy Emesis

Bradycardia Explanation: Bradycardia: A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. The nurse should monitor for bradycardia, a clinical manifestation associated with this electrolyte imbalance. Hyperactive deep tendon reflexes: A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Hyperactive deep tendon reflexes are associated with hypocalcemia and hypomagnesemia, not hyperkalemia. Lethargy: A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Lethargy is a clinical manifestation associated with hyponatremia, hyponatremia, hypercalcemia, or hypermagnesemia, not hyperkalemia. Emesis: A serum potassium concentration of 5.2 mEq/L indicates hyperkalemia. Emesis is not a clinical manifestation associated with hyperkalemia.

Which clinical manifestations should the nurse anticipate when assessing a patient who is diagnosed with hypernatremia? Select all that apply. Hyperactive deep tendon reflexes Confusion Thirst Lethargy

Confusion Thirst Lethargy Seizures

The nurse is providing care to a patient who is diagnosed with end-stage renal disease. Which clinical manifestation assessed by the nurse indicates the patient is experiencing hyperphosphatemia? Decreased blood pressure Anorexia Irritated and itchy eyes Confusion

Irritated and itchy eyes

Match the physical assessment with the data indicating an electrolyte imbalance. Spasm of the facial muscles when facial nerve is tapped Spasm of the hand and wrist muscles after blood pressure cuff is inflated Foot kicks wildly when patellar tendon is tapped Chvostek sign Deep tendon reflex Trousseau sign

Spasm of the facial muscles when facial nerve is tappedChvostek sign Spasm of the hand and wrist muscles after blood pressure cuff is inflatedTrousseau sign Foot kicks wildly when patellar tendon is tappedDeep tendon reflex