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.
The nurse conducts the health history as the first step in the nursing assessment
Colostomy sites (blue area is where colon was removed).
sodium
assessment techniques
Geriatric Depression (Mood Assessment) Scale
Giger and Davidhizar’s Transcultural Assessment Model.