Disrupted Homeostasis Questions

A nurse is providing discharge education to a client who has hypokalemia. Which statement by the client indicates to the nurse the client understands the teaching?

"I will continue to take my laxatives as needed for my constipation."
"I should replace my salt substitute with table salt."
"I should avoid consuming green vegetables."
"I will report if I experience muscle weakness to my provider."

"I will report if I experience muscle weakness to my provider."

Muscle weakness is a sign of hypokalemia, so it is important to teach the client to monitor and report this to the provider. This statement indicates an understanding of the instructions.

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The client should avoid chronic use of laxatives to relieve constipation because it can cause hypokalemia. 

A nurse is planning care for a client who has a serum potassium level of 2.0 mEq/L (expected: 3.5 to 5 mEq/L). Which of the following prescriptions should the nurse anticipate including in the plan of care?

Administer dextrose 5% in 0.45% sodium chloride with 40 mEq/L potassium chloride
Initiate insulin therapy
Monitor for nephrolithiasis
Administer an IV infusion of 0.9% sodium chloride with potassium chloride

Administer an IV infusion of 0.9% sodium chloride with potassium chloride

A client who has severe hyponatremia will require IV potassium chloride replacement at 10 to 20 mEq/hr.

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The nurse should not plan to assess for nephrolithiasis, as this is seen with hypercalcemia, not hypokalemia.

The nurse should not plan to initiate insulin therapy. Insulin therapy is used for hyperkalemia and will further decrease the client's potassium level.

Potassium should not be mixed in solutions that have dextrose. The dextrose can cause an increase in the secretion of insulin which can further worsen the hypokalemia.

A nurse is caring for a client who has hypernatremia and is receiving a rapid infusion of IV fluids. The nurse should monitor for which of the following manifestations?

Hypoactive reflexes
Hypotension
Decreased urine output
Seizures

Seizures

The nurse should monitor for seizures in this client. Administering IV fluids too rapidly to correct hypernatremia can result in cerebral edema, which leads to seizures.

A nurse is caring for several clients on a medical-surgical unit. Which of the following client diagnoses places the client at risk for fluid volume excess (FVE)? (Select all that apply.)



Diabetic ketoacidosis


Heart failure


Renal failure


Diabetes insipidus


End-stage liver disease


Preeclampsia

Heart failure is correct. Clients who have heart failure, end stage liver disease, renal failure, and preeclampsia are at risk for FVE.

Renal failure is correct. Clients who have renal failure, heart failure, end stage liver disease, renal failure, and preeclampsia are at risk for FVE.

End-stage liver disease is correct. Clients who have renal failure, heart failure, end-stage liver disease, and preeclampsia are at risk for FVE.

Preeclampsia is correct. Clients who have renal failure, heart failure, end-stage liver disease, and preeclampsia are at risk for FVE.

Diabetes insipidus is incorrect. Clients who have diabetes insipidus are at risk for fluid volume deficit (FVD) due to excessive urination related to deficient antidiuretic hormone (ADH); however, clients with heart failure, renal failure end stage liver disease, and preeclampsia are at risk for FVE.

Diabetic ketoacidosis is incorrect. Clients who have diabetic ketoacidosis are associated with fluid volume deficit (FVD) due to osmotic diuresis; however, clients with heart failure, renal failure, end stage liver disease, and preeclampsia are at risk for FVE.

A nurse is caring for 4 clients on a medical-surgical unit. Which of the following client findings increases the risk for hypercalcemia? (Select all that apply.)



Clients who have prolonged immobilization


Clients who have bone cancer


Clients who are postoperative following a thyroidectomy


Clients who have hyperparathyroidism


Clients who have vitamin D deficiency

Clients who have prolonged immobilization is correct. Prolonged immobilization can result in hypercalcemia related to inhibition of parathyroid hormone release.

Clients who have bone cancer is correct. Clients who have malignancies such as bone cancer may develop hypercalcemia due to bone breakdown.

Clients who have hyperparathyroidism is correct. Clients who have hyperparathyroidism are at increased risk for hypercalcemia.

Clients who have vitamin D deficiency is incorrect. Clients who have vitamin D deficiency are at increased risk for hypocalcemia, not hypercalcemia, due to inability of gastrointestinal tract to absorb calcium.

Clients who are postoperative following a thyroidectomy is incorrect. Clients who are postoperative following a thyroidectomy are at increased risk for hypocalcemia, not hypercalcemia, due to removal of the parathyroid gland.

A nurse is teaching a nursing student about hyperventilation and acid-base balance. Which of the following statements should the nurse include in the teaching?

"Hyperventilation causes a buildup of bicarbonate, resulting in an acidotic state."
"Hyperventilation causes an elimination of carbon dioxide that results in an alkalotic state."
"Hyperventilation causes a buildup in carbon dioxide, resulting in an acidotic state."
"Hyperventilation causes an elimination of bicarbonate that results in an alkalotic state."

"Hyperventilation causes an elimination of carbon dioxide that results in an alkalotic state."

Hyperventilation eliminates excess carbon dioxide from the body, which decreases the amount of acid being produced, resulting in an alkalotic state.

A nurse is caring for a client who has fluid volume deficit (FVD). Which of the following manifestations may be consistent with this diagnosis? (Select all that apply.)



Blood pressure 92/66 mm Hg


Heart rate 128/min


Lower extremity edema


Urine output 100 mL in 4 hr


Jugular vein distention

Blood pressure 92/66 mm Hg is correct. A client whose systolic blood pressure is less than 100mm Hg may indicate the presence of fluid volume deficit (FVD).

Heart rate 128/min is correct. A client who has heart rate of 128/min may indicate the presence of fluid volume deficit.

Urine output 100 mL in 4 hr is correct. A decrease in urine output may indicate the presence of fluid volume deficit.

Jugular vein distention is incorrect. Jugular vein distention is a manifestation of fluid volume excess, not fluid volume deficit.

Lower extremity edema is incorrect. Lower extremity edema is a manifestation of fluid overload; however, BP 92/66, heart rate 128/min, urine output 100 mL in 4 hours may be manifestations consistent with FVD.

A nurse is caring for a client who has fluid volume deficit related to hemorrhage. The nurse should identify that the client is at increased risk for which of the following conditions?

Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
Increased systolic pressure
Cerebral hypoperfusion
Metabolic alkalosis

Cerebral hypoperfusion

Fluid volume deficit can result in decreased blood flow and oxygen and places the client at risk for decreased perfusion to the brain and other vital organs.

A nurse is providing education to a group of nursing students. Which of the following conditions should the nurse explain causes fluid to move from the interstitial compartment to the vascular compartment?

Elevated serum sodium
Decreased serum calcium
Excess fluid volume
Hypotension

Elevated serum sodium

Elevated serum sodium exerts osmotic pressure, which pulls fluid from the interstitial compartment into the vascular compartment. Sodium is the major cation found in the extracellular fluid. To achieve homeostasis, water will move from an area of low osmolality through a permeable membrane to an area of high osmolality.

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Hypomagnesemia and thyroidectomy can cause hypocalcemia. 

Excess fluid volume results in increased hydrostatic pressure, which moves fluid from the vascular compartment into the interstitial compartment.

Hypotension is due to decreased vascular volume and results in decreased hydrostatic pressure. It does not cause a fluid shift from the interstitial compartment to the vascular compartment.

A nurse is planning discharge teaching for a client who has been treated for hypocalcemia. Which of the following symptoms should the nurse instruct the client to report to the provider? (Select all that apply.)



Irregular heartbeat


Anxiety


Weakness


Constipation


Abdominal distention


Numbness of fingertips

Irregular heartbeat

Anxiety

Weakness

Numbness of fingertips

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Constipation is a manifestation of hypercalcemia

Abdominal distention is a manifestation of hypercalcemia

A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) about interventions for shortness of breath. Which of the following should the nurse include in the teaching?

Sit in a tripod position
Lay in a prone position
Use panting breaths with frequent pauses
Use caution when taking sedatives

Sit in a tripod position

The nurse should include in the teaching for the client to assume a tripod position when experiencing shortness of breath.

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Panting breaths will not relieve shortness of breath and can instead cause respiratory alkalosis. 

A nurse is caring for a client who has hyponatremia. Which of the following manifestations of hyponatremia should the nurse identify as the priority for immediate intervention?

Weakness
Anorexia
Lethargy
Hyperactive reflexes

Lethargy

Lethargy is a manifestation of alteration in neurologic status, which is the most serious manifestation of hyponatremia and requires immediate intervention.

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A nurse is caring for a client who has hypokalemia. Which of the following manifestations should the nurse expect? (Select all that apply.)



Muscle cramps


Flattening of T waves on a cardiac monitor


Vomiting


Hyperactive bowel sounds


Diarrhea

Muscle craps is correct. The nurse should recognize muscle cramps, vomiting, and the flattening of T waves on a cardiac monitor are manifestations of hyperkalemia.

Flattening of T waves on a cardiac monitor is correct. The nurse should recognize muscle cramps, vomiting, and the flattening of T waves on a cardiac monitor are manifestations of hypokalemia.

Vomiting is correct. The nurse should recognize muscle cramps, vomiting, and the flattening of T waves on cardiac monitor are manifestations of hypokalemia.

Hyperactive bowel sounds is incorrect. The nurse should recognize hyperactive bowel sounds is a manifestation of hyperkalemia.

Diarrhea is incorrect. The nurse should recognize that diarrhea is a manifestation of hyperkalemia.

A nurse is teaching a client who has hyponatremia. Which of the following statements should the nurse include in the teaching?

"You will need to restrict fluids to prevent hyponatremia from recurring."
"You will need to have a brain natriuretic peptide drawn every 3 months."
“You will need to be on a 2 grams sodium diet.”
"You will need to wear a Holter monitor for 3 days after discharge."

"You will need to restrict fluids to prevent hyponatremia from recurring."

The nurse should include this in the education. Clients may need to restrict fluids to prevent reoccurrence of hyponatremia.

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Clients who have hypokalemia or hyperkalemia rather than hyponatremia, are at higher risk for cardiac dysrhythmias.

A 2 g sodium diet is a sodium restrictive diet which is not needed with a client who has hyponatremia.

A nurse is caring for a client who has liver cirrhosis. Which of the following should the nurse understand is causing the client's ascites?

Decreased fluid volume
Decreased blood flow to the kidneys
Decreased serum sodium
Decreased vascular resistance

Decreased blood flow to the kidneys

The cirrhotic liver causes pressure on the blood vessels leading to increased vascular resistance and decreased blood flow to the kidneys. This decreased blood flow to the kidneys triggers the kidneys to retain water and sodium chloride, and results in ascites.

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client's respiratory rate is 8/min and shallow with an oxygen saturation of 80%. Which of the following acid-base imbalances is the client most likely experiencing?

Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
Respiratory alkalosis

Respiratory acidosis

Respiratory acidosis occurs in clients who have problems due to respiratory mechanics or lung disease, such as COPD, where carbon dioxide builds up in the circulation due to hypoventilation.

A nurse is caring for several clients on a medical-surgical unit. Which of the following clients are at risk for hypernatremia? (Select all that apply.)



The client who has diabetes insipidus


The client who is receiving hypotonic IV fluids


The client who has dementia


The client who has gastroenteritis


The client who has diabetic ketoacidosis

The client who has diabetes insipidus is correct. Clients who have diabetes insipidus are at increased risk for hypernatremia due to the loss of total body water.

The client who has dementia is correct. Clients who have physical impairments such as right-sided weakness, psychosocial conditions including dementia, or decreased thirst sensation are at risk for hypernatremia related to decreased fluid volume compared to level of serum sodium.

The client who has gastroenteritis is correct. Clients who have gastroenteritis are at risk for hyponatremia, which occurs when total body fluid decreases more than total body sodium, and is associated with diuretics and gastrointestinal losses.

 The client who has diabetic ketoacidosis is correct. Clients who have diabetes insipidus, diabetic ketoacidosis, dementia, and gastroenteritis are at risk for hypernatremia due to loss of fluid volume compared to level of serum sodium.

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The client who is receiving hypotonic IV fluids is incorrect. Hyponatremia, not hypernatremia, can occur when excessive administration of IV fluids or ingestion of water results in an increase of total body water without an alteration in body sodium or extracellular fluid.

A nurse is caring for a client who has a potassium level of 5.2 mEq/L (3.5 to 5 mEq/L). Which of the following findings from the client's medical history should the nurse identify as a potential contributor to the client's potassium level?

IV insulin administration
Heart failure
Use of ACE inhibitors
Nephrotic syndrome

Use of ACE inhibitors

A nurse is teaching a client who has hypercalcemia about medications that can increase calcium. Which of the following medications should the nurse include in the teaching?

Montelukast
Amlodipine
Rivaroxaban
Lithium

Lithium

Tamoxifen, theophylline, thiazides, vitamin D, lithium, vitamin A are examples of medications that will increase calcium. 

A nurse is planning discharge education about diuretic therapy for a client who has heart failure. Which of the following should the nurse instruct the client to report to the provider?

Palpitations, fainting, decreased sensation in the feet
Confusion, muscle twitching, headache
Muscle weakness, irritability, constipation
Aching joints, abdominal distention, anorexia

Muscle weakness, irritability, constipation

Diuretic therapy, other than potassium-sparing diuretics, can lead to hypokalemia. The client should report muscle weakness, fluttery heart, and constipation to the provider as these are all signs of hypokalemia.

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Confusion, muscle twitching, and headache are manifestations of hypernatremia and the nurse should not include them in the teaching. 

Aching joints, abdominal distention, and anorexia are manifestations of hypercalcemia and the nurse should not include them in the teaching. 

Palpitations, fainting, and decreased sensation in the feet are manifestations of hyperkalemia and the nurse should not include them in the teaching. 

A nurse is providing care for a client who has a new diagnosis of anxiety. The client's heart rate is 100/min, respiratory rate is 34/min, and the client reports numbness and tingling of the hands. Which of the following acid-base imbalances should the nurse suspect?

Respiratory acidosis
Metabolic alkalosis
Metabolic acidosis
Respiratory alkalosis

Respiratory alkalosis

The client is manifesting anxiety, rapid heart rate, rapid respiratory rate, and numbness and tingling of the hands, which are all manifestations of respiratory alkalosis.

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The client who has respiratory acidosis will have manifestations such as difficulty sleeping and anxiety. They might also have cyanosis, as well as some respiratory alterations such as shortness of breath. 

A client who has metabolic alkalosis will have neurologic alterations, including confusion, due to reduced oxygenation, muscle weakness, paresthesia, and dysrhythmias. 

A client who has metabolic acidosis will have manifestations such as nausea, vomiting, and hemodynamic instability if the imbalance is severe. 

A nurse is caring for a client who has hypercalcemia related to hyperparathyroidism. Which of the following should the nurse identify as potential complications of hypercalcemia? (Select all that apply.)



Renal calculi


Seizures


Tetany


Bone pain


Decreased blood clotting


First-degree atrioventricular block

Renal calculi is correct. Hypercalcemia can result in complications such as renal calculi, first-degree atrioventricular block, and bone pain.

Bone pain is correct. The nurse should identify bone pain as a complication of hypercalcemia.

First-degree atrioventricular block is correct. Hypercalcemia can result in complications such as renal calculi, first-degree atrioventricular block, and bone pain.

Decreased blood clotting is incorrect. Decreased blood clotting is not a complication of hypercalcemia; however, hypercalcemia can result in complications such as renal calculi, first-degree atrioventricular block, and bone pain.

Seizures is incorrect. Seizures are a complication of hypocalcemia, rather than hypercalcemia; however, hypercalcemia can result in complications such as renal calculi, first-degree atrioventricular block, and bone pain.

Tetany is incorrect. The nurse should identify that hypocalcemia, rather than hypercalcemia, causes tetany; however, hypercalcemia can result in complications such as renal calculi, first-degree atrioventricular block, and bone pain.

A nurse is providing teaching to a student about fluid volume deficit related to vomiting and diarrhea. Which of the following statements should the nurse include in the teaching about the body's response to fluid volume deficit?

“The body responds to fluid volume deficit by releasing antidiuretic hormone.”
"When fluid volume deficit is present, the body will inhibit the thirst center."
“Vagal nerve inhibition occurs when the body has low fluid levels.”
“The body will block the release of vasopressin in response to fluid volume deficit.”

“The body responds to fluid volume deficit by releasing antidiuretic hormone.”

The nurse should teach the student that release of antidiuretic hormone (ADH) will stimulate the kidneys to retain water, thereby increasing vascular water volume.

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The presence of a fluid volume deficit releases, rather than blocks, vasopressin, which is another name for ADH.

Assessment Findings	Hypernatremia	Fluid Volume Excess	Fluid Volume Deficit
Agitation
Lightheadedness
Decreased skin turgor
Dyspnea
Dry mucous membranes
Muscle twitching
Hypertension

When analyzing cues, the nurse should recognize that manifestations of fluid volume excess include hypertension and dyspnea. Fluid volume excess can occur for a variety of reasons including heart failure,  renal failure, or an imbalance in antidiuretic hormone.

When analyzing cues, the nurse should recognize that manifestations of fluid volume deficit include agitation, decreased skin turgor, dry mucous membranes, and lightheadedness. Fluid deficit can occur when a client is unable to ingest fluids or when the body uses more fluid than is being consumed.

When analyzing cues, the nurse should recognize that manifestations of hypernatremia include irritability, decreased skin turgor, dry mucous membranes, and muscle twitching. Hypernatremia can occur when excessive water is lost through the renal or gastrointestinal systems or through the skin. The loss of water without a loss of sodium results in an increase in sodium levels.