Textbook of Medical-Surgical Nursing

BRUNNER & SUDDARTH'S TEXTBOOK OF MEDICAL-SURGICAL NURSING 15TH EDITION HINKLE TEST BANK
Rationale: In older adult clients, the clinical manifestations of fluid and electrolyte disturbances may
be subtle or atypical. For example, fluid deficit may cause confusion or cognitive impairment in the
older adult. There is no specific evidence given for the need for readmission to the hospital. Confusion
is never normal, common, or expected in older adults.
PTS: 1 REF: p. 234
NAT: Client Needs: Physiological Integrity: Basic Care and Comfort
TOP: Chapter 10: Principles of Fluid and Electrolytes
KEY: Integrated Process: Teaching/Learning
BLM: Cognitive Level: Apply
NOT: Multiple Choice
16. A client comes into the emergency department (ED) by ambulance with a hip fracture after slipping
and falling while at home. The client is alert and oriented but anxious and reports thirst. The client’s
pupils are equal and reactive to light and accommodation, and the heart rate is elevated. An indwelling
urinary catheter is inserted, and 40 mL of urine is present. What is the nurse's most likely explanation
for the client’s urinary output?
A. The client urinated prior to arrival to the ED and will probably not need to have the
urinary catheter kept in place.
B. The client likely has a traumatic brain injury, lacks antidiuretic hormone, and needs
vasopressin.
C. The client is experiencing symptoms of heart failure and is releasing atrial natriuretic
peptide, which results in decreased urine output.
D. The client is having a sympathetic reaction, which has stimulated the renin–
angiotensin–aldosterone system, which results in diminished urine output.
ANS: D
Rationale: In response to the acute stress of falling at home, the sympathetic nervous system is
activated. Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal
perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II,
with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the
sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of
renin, which decreases urine production. Based on the nursing assessment and mechanism of injury,
this is most likely causing the lower urine output. The client urinating prior to arrival to the ED is
unlikely; the fall and hip injury would make the ability to urinate difficult. No assessment information
indicates the client has a head injury or heart failure.
PTS: 1 REF: p. 232
NAT: Client Needs: Physiological Integrity: Reduction of Risk Potential
TOP: Chapter 10: Principles of Fluid and Electrolytes
KEY: Integrated Process: Nursing Process
BLM: Cognitive Level: Analyze
NOT: Multiple Choice
17. A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best
reduce the client's risk for electrolyte disturbances?
A. Maintain a low-sodium diet.
B. Encourage the use of over-the-counter calcium supplements.
C. Ensure the client has sufficient potassium intake.
D. Encourage fluid intake.
ANS: C
Rationale: Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to
maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a
low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra
calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.
C L I C K H E R E T O D O W N L O A D C O M P L E T E T E S T B A N K S