Fundamentals Exam 4: Case Study/EAQ/ZoomReview
dysurea
painful urination
A client with a diagnosis of malabsorption syndrome exhibits a symptom of spastic muscle spasms. Which electrolyte is responsible for this symptom? Sodium Calcium Potassium Phosphorus
Calcium The muscle contraction-relaxation cycle requires an adequate serum calcium/phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. The major route of sodium excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium, because they exist in a specific ratio, phosphorus is not related to the development of tetany.
how to prevent constipation
-high fiber diet -increase fluid intake -increase ambulation
magnesium
1.5-2.5
potassium
3.5-5.0 too low or too high can cause arrythmia
how much fluid needs to be drank in order to be healthy
8-10 glasses of water 1000-2000 mL
calcium
8.4-10.5
A client who sustained a cerebrovascular accident (CVA, also known as a "brain attack") becomes incontinent of feces. Which nursing intervention is most important for supporting the success of the client's bowel training program? Use prescribed medications to induce elimination. Adhere to a definite time for attempted evacuations. Consider previous habits associated with the client's defecation. Time scheduled eliminations to take advantage of the gastrocolic reflex.
Adhere to a definite time for attempted evacuations.
A male client with a brain attack (cerebrovascular accident) is incontinent of urine. Which action would the nurse encourage to help the client reestablish bladder control? Assume a standing position for voiding. Void every 4 hours at set times. Void more frequently in the afternoon. Drink a minimum of 4 L of fluid daily.
Assume a standing position for voiding.
lab to test kidney function
BUN (high means dehydration) specific gravity: numbers show how well the kidneys are diluting the urine creatinine: urine pH level:
Which measures would the nurse take to prevent skin breakdown for a confused client experiencing bowel incontinence? Answer the client's call light immediately to prevent incontinence. Place a waterproof pad under the client to prevent soiling the linens. Check the client's buttocks at least every 2 hours and clean after incontinence. Offer toileting to the client every 2 hours to prevent incontinence.
Check the client's buttocks at least every 2 hours and clean after incontinence.
Which conclusion would the nurse make about the assessment finding of a client's very pale-yellow-colored urine? Dilute urine Hematuria Concentrated urine Myoglobinuria
Dilute urine
A client with Parkinson disease reports problems with bowel elimination. Which instruction should the nurse provide for the client? Eat a banana daily. Decrease fluid intake. Take cathartics regularly. Increase residue in the diet.
Increase residue in the diet. Increasing residue in the diet produces bulk, which stimulates defecation; the muscles used in defecation are weak in clients with Parkinson disease. Bananas are binding and will intensify the problem of constipation. Decreasing fluid intake will intensify the problem; fluids need to be increased to keep the stool soft. Cathartics are irritating to the intestinal mucosa, and their regular administration promotes dependence.
A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse would monitor for which clinical manifestations of the electrolyte deficiency? Select all that apply. One, some, or all responses may be correct. Diplopia Skin rash Leg cramps Tachycardia Muscle weakness
Leg cramps Muscle weakness Leg cramps occur with hypokalemia because of potassium deficit. Muscle weakness occurs with hypokalemia because of the alteration in the sodium potassium pump mechanism. Diplopia does not indicate an electrolyte deficit. A skin rash does not indicate an electrolyte deficit. Tachycardia is not associated with hypokalemia; bradycardia is.
The nurse is caring for an older adult client who has constipation. Which independent nursing intervention helps reestablish a normal bowel pattern? Administer a mineral oil enema. Offer 1 cup of fluid every hour. Manually remove fecal impactions. Offer a cup of prune juice.
Offer a cup of prune juice.
An older client is admitted to the hospital for rehydration therapy after 3 days of diarrhea. In addition to sodium, which electrolyte would the nurse be most concerned about? Calcium Chlorides Potassium Phosphates
Potassium Potassium, sodium, and bicarbonate are the electrolytes most often lost with diarrhea. With diarrhea, these electrolytes are excreted via the gastrointestinal tract before they can be absorbed. Hypokalemia can cause cardiac dysrhythmias. Serum calcium levels are related to parathyroid function and calcium metabolism. Although the chloride level may be affected by diarrhea, it is not the greatest concern. Phosphate levels are regulated by calcium metabolism and parathormone.
Which electrolyte, if found on urinalysis, would alert the nurse to the possibility of kidney damage? Protein Calcium Potassium Phosphate
Protein Protein is usually not excreted in urine because it is a large molecule. When found, it indicates kidney disease. Excess calcium is excreted in urine. Potassium is excreted by the kidneys to maintain electrolyte balance. Excess phosphate is excreted in urine.
Which intervention would the nurse implement first when providing care for an older adult male client who is immobile and incontinent of urine? Restrict the client's fluid intake. Regularly offer the client a urinal. Apply incontinence pants. Insert an indwelling urinary catheter.
Regularly offer the client a urinal.
Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client? Serum sodium of 139 mEq/L (139 mmol/L) Serum chloride of 100 mEq/L (100 mmol/L) Serum calcium of 10.2 mg/dL (2.55 mmol/L) Serum potassium of 7.2 mEq/L (7.2 mmol/L)
Serum potassium of 7.2 mEq/L (7.2 mmol/L) Hyperkalemia causes dysrhythmias and cardiac arrest. The normal serum potassium concentration ranges between 3.5 and 5.0 mEq/L (3.5-5.0 mmol/L). A concentration of 7.2 mEq/L (7.2 mmol/L) indicates hyperkalemia. The normal concentration of sodium in the serum ranges between 135 and 145 mEq/L (135-145 mmol/L). The normal chloride concentration ranges between 96 and 106 mEq/L (96-106 mmol/L). The normal serum calcium level ranges between 9 and 10.5 mg/dL (2.25-2.625 mmol/L).
Which electrolyte deficiency triggers the secretion of renin? Sodium Calcium Chloride Potassium
Sodium Low sodium ion concentration causes decreased blood volume, thereby resulting in decreased perfusion. Decreased blood volume triggers the release of renin from the juxtaglomerular cells. Deficiencies of calcium, chloride, and potassium do not stimulate the secretion of renin.
Which condition would the nurse suspect if the client reports passing urine involuntarily while coughing? Enuresis Pneumaturia Urinary retention Stress incontinence
Stress incontinence
Which action would the nurse take for an older client with Alzheimer disease who has intermittent episodes of urinary incontinence? Point out the behavior to the client. Obtain incontinence pads for the client. Take the client to the bathroom at regular intervals. Encourage the client to call for help when there is an urge to urinate.
Take the client to the bathroom at regular intervals.
Which approach would the nurse take for an older adult client who is confused, does not recognize family members, and often soils clothing with feces and urine? Toileting the client every 2 hours Placing the client in orientation therapy Supervising the client's bathroom activities closely Explaining to the client how offensive the behavior is to others
Toileting the client every 2 hours
While collecting a client's urine sample, which condition would the nurse suspect if the sample has a strong odor of ammonia? Malabsorption Bladder cancer Diabetic ketoacidosis Urinary tract infection
UTI
at what point should we consider placing a foley catheter in somebody?
as a last resort only if it is needed bc of the high risk for infection remove as soon as we can insert catheter with dominant hand
interventions for diarrhea
barrier cream
two electrolytes that have an inverse relation
calcium and phosphorus when one is high, the others are low
disease process that has to do with antidiuretic hormone
diabetes insipidus
hypovolemia
dry skin, weight loss, decreased urine output, hypotension
signs and symptoms of fluid overload
edema, crackles in lungs, shortness of breath raise head of bed, elevate feet,
most at risk for dehydration
elderly and infants as we age we lose sense of thirst
how to treat hypokalemia
give potassium by pill or diluted IV never push potassium IV
how to treat hypernatremia?
give them fluid!! hypernatremia means TOO MUCH SODIUM
Loop Diuretics
hold on to potassium and excrete it out with urine flow
when giving a patient with hypertension a thiazide diuretic, you should closely monitor
hypokalemia (potassium)
potassium food sources
leafy greens, banana, fresh fruit, potatoes
isotonic
leaves cells as is 0.9 normal saline IV keeps us hydrated by adding more normal fluid
enema postions
left sims position why? because of angle of anus and rectum
how much urine is appropriate for a healthy human being?
minimum 30ml per hour
medication that causes constipation
opiods
hypocalcimia symptoms
tetany: tingling and numbness
what organ in the body is most effected by potassium level?
the heart
functional incontinence
the person has bladder control but cannot use the toilet in time
volume
what goes in must go out
Which electrolyte found in intracellular fluid would the nurse consider most important? Sodium Calcium Chloride Potassium
Potassium The concentration of potassium is greater inside the cell and is important in establishing a membrane potential, a critical factor in the cell's ability to function. Sodium is the most abundant cation of the extracellular compartment, not the intracellular compartment. Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not intracellular, anion.
EXAM 4: 50 questions
17 question on bowel 17 questions urinary 16 questions fluid and electrolytes
An older adult is having urinary incontinence. Which nursing interventions would help the client? Select all that apply. One, some, or all responses may be correct. Provide nutritional support. Provide voiding opportunities. Avoid indwelling catheterization. Provide beverages and snacks frequently. Promote measures to prevent skin breakdown.
Provide voiding opportunities. Avoid indwelling catheterization. Promote measures to prevent skin breakdown. An older adult should be provided voiding opportunities to minimize urinary incontinence. Indwelling catheterization should be avoided because this action increases the risk of infection, weakens bladder tone, and may cause discomfort. Measures to prevent skin breakdown should be taken because the client may develop skin problems due to incontinence. Nutritional support and frequent beverages and snacks should be provided to a client with malnutrition.
Which type of incontinence can be improved by teaching the client Kegel exercises? Reflex incontinence Stress incontinence Overflow incontinence Functional incontinence
Stress incontinence is the involuntary loss of urine during coughing, laughing, or sneezing. In women, this is often seen after having children. Kegel exercises increase the perineal muscle tone, helping control involuntary voiding. Overflow incontinence is caused by overdistention of the bladder, and exercises will not help. Reflex incontinence is preceded by abnormal detrusor contractions from neurological abnormalities. Functional incontinence is associated with environmental or cognitive factors due to which the client is unable to get to the toilet or does not have the necessary cognitive abilities to use the toilet.
symptoms of uti
flank pain (indicated kidney infection) confusion in elderly cloudy urine odorous urine
prolonged diarrhea could lead to
hypotension fever poor skin turgor severe dehydration possible tachycardia (increased HR)
intracellular fluid vs extracellular fluid
intra: fluids found inside the cells extra: fluid found outside the cells
hypotonic
pulls fluid into cells and makes them larger give .45 normal saline IV
hypertonic
pulls fluid out of cells and makes them shrink 3% sodium chloride IV
how to treat hyponatremia?
put the person on fluid restriction
when doing an assessment, and you find an enlarged bladder.. what type of questions should be asked?
when did you go to the bathroom last? do a bladder scan ask about their history and if this has happened before
