a 73 year old man comes into the emergency department ed by ambulance after slipping on a small carpet in his home the patient fell on his hip with a

ATI RN

ATI Fluid Electrolyte and Acid-Base Regulation

1. . A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of urine is present. What is the nurses most likely explanation for the low urine output?

A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept in place.
B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in decreased urine output.
D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that results in diminished urine output.

Correct answer: D

Rationale:

2. The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?

A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
B. Observe for swelling of the neck, tracheal deviation, and severe pain.
C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.

Correct answer: D

Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia. Monitoring for an elevated thyroid-stimulating hormone (choice A) is not relevant in assessing for hypocalcemia. Observing for swelling of the neck, tracheal deviation, and severe pain (choice B) are more related to airway compromise. Evaluating the quality of the patient's voice postoperatively (choice C) is important but not a primary sign of hypocalcemia.

3. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patients skin turgor?

A. Overhydration is common among healthy older adults.
B. Dehydration causes the skin to appear spongy
C. Inelastic skin turgor is a normal part of aging
D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale:

4. Which electrolyte is important in the formation of the thyroid hormones?

A. Sodium
B. Iodine
C. Iron
D. Chloride

Correct answer: B

Rationale: Iodine is the correct answer because it is essential for the synthesis of thyroid hormones. The thyroid gland incorporates iodine into thyroid hormones such as thyroxine (T4) and triiodothyronine (T3). These hormones are crucial for regulating metabolism, growth, and development. Sodium, iron, and chloride are not directly involved in the formation of thyroid hormones, making them incorrect choices.

5. A patient's lab results show a slight decrease in potassium. The physician has declined to treat with drug therapy but has suggested increasing the potassium through diet. Which of the following would be a good source of potassium?

A. Apples
B. Asparagus
C. Carrots
D. Bananas

Correct answer: D

Rationale: Bananas are an excellent source of potassium, making them a good choice to increase potassium levels through diet. While apples, asparagus, and carrots are nutritious, they are not particularly high in potassium compared to bananas. Therefore, choosing bananas would be more effective in increasing the patient's potassium intake.