Author Question: A client has a serum sodium level of 157 mEq/L. Which area of assessment is the priority? 1. ... (Read 64 times)

jessicacav · **on:** Jul 23, 2018

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

Question 2

A nurse is caring for a client with a serum potassium level of 6.9 mEq/L. When planning care, which body system will be most profoundly affected by this value?

1. The respiratory system
2. The cardiovascular system
3. The hematological system
4. The genitourinary system

kardosa007 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

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.

Answer to Question 2

Correct Answer: 2
Rationale 1: The respiratory system is not the body system most profoundly affected by potassium imbalance.
Rationale 2: This value represents hyperkalemia. Both hyper- and hypokalemia are associated with fatal dysrhythmias and serious neuromuscular disorders.
Rationale 3: The hematological system is not the body system most profoundly affected by potassium imbalance.
Rationale 4: The genitourinary system is not the body system most profoundly affected by potassium imbalance.
Global Rationale: This value represents hyperkalemia. Both hyper- and hypokalemia are associated with fatal dysrhythmias and serious neuromuscular disorders. The respiratory system, hematological system, and genitourinary system are not the most profoundly affected by potassium imbalance.