A client has a serum sodium level of 157 mEq/L. Which area of assessment is the priority?
1. Muscle pain
2. Daily weight
3. Thirst level
4. Level of consciousness
Correct Answer: 4
Rationale 1: Muscle fatigue, not pain, is associated with hypernatremia.
Rationale 2: The daily weight is not the nurse's highest priority for this client.
Rationale 3: Thirst is a normal mechanism when a client's serum osmolality increases.
Rationale 4: Hypernatremia can cause increased intracranial pressure. This should be reported to the health care provider immediately.
Global Rationale: Hypernatremia can cause increased intracranial pressure. This should be reported to the health care provider immediately. Muscle fatigue, not pain, is associated with hypernatremia. The daily weight is not the nurse's highest priority for this client. Thirst is a normal mechanism when a client's serum osmolality increases.
You might also like to view...
The nurse is instructing a patient with a left fractured tibia how to walk with crutches. Which instruction would be appropriate?
A) Use the axillae to help carry the weight. B) All weight should be on the hands. C) Keep feet 11" (28 cm) apart to provide stability and a wide base of support. D) Take long strides to maintain maximum mobility.
As a nurse is obtaining a health history from a patient, the nurse uses comments such as "go on." Which technique is the nurse using?
a. Cues b. Inferences c. Back-channeling d. Termination
A nurse and an elderly client with chronic back pain are in the working phase of the nurse–client relationship. Which of the following activities occur in the working phase?
A) The client identifies one or more health problems. B) The nurse tries to avoid retarding the client's independence. C) The nurse is courteous and actively listens to the client. D) The nurse ensures that the client manages independently.
In the current practice of childbirth preparation, emphasis is placed on:
a. The Dick-Read (natural) childbirth method. b. The Lamaze (psychoprophylactic) method. c. The Bradley (husband-coached) method. d. Having expectant parents attend childbirth preparation in any or no specific method.