A nurse in a medical unit has noted that a client's potassium level is elevated at 6.1 mEq/L. The nurse has notified the physician, removed the banana from the client's lunch tray, and is performing a focused assessment. When questioned by the client for the rationale for these actions, which of the following explanations is most appropriate?

Correct Answer: A

Rationale: Rationale for Correct Answer A (Your potassium level is high, and so I need you to let me know if you feel numbness, tingling, or weakness): 1. Acknowledges the high potassium level directly. 2. Provides specific symptoms related to hyperkalemia. 3. Encourages client involvement in monitoring and reporting symptoms promptly. Summary of Incorrect Answers: B: Mentions brain function changes, which is not a primary concern with elevated potassium levels. C: Focuses on heart-related symptoms only, missing other important symptoms of hyperkalemia. D: Suggests resolving high potassium levels solely through IV fluid changes, which is not always sufficient.

Correct Answer: A

Rationale: The correct answer is A: Administer calcium gluconate IV. In severe hypermagnesemia, excess magnesium suppresses neuromuscular function, leading to diminished reflexes and respiratory depression. Calcium gluconate antagonizes the effects of hypermagnesemia and can quickly restore neuromuscular function, including respiratory drive. Prioritizing this intervention is crucial to prevent further respiratory compromise. Choice B (Initiate dialysis immediately) may be necessary for severe cases, but it is not the initial priority in managing acute symptoms. Choice C (Start an infusion of potassium chloride) is incorrect as it can worsen hypermagnesemia by further disrupting electrolyte balance. Choice D (Provide oral phosphate supplements) is not appropriate for immediate management of severe hypermagnesemia.

Correct Answer: C

Rationale: The correct answer is option C, a person with a serious infection and fever. During an infection and fever, the body's metabolic rate increases as part of the immune response to combat the illness. This heightened metabolic rate necessitates additional nutritional support to meet the increased energy demands required for the body to fight off the infection and aid in the healing process. Option A, a healthy young adult who works in an office, would not typically have an increased metabolic rate unless engaged in strenuous physical activity. Thus, this individual may not require additional nutritional interventions beyond a well-balanced diet. Option B, a retired person living in a temperate climate, is unlikely to have an increased metabolic rate unless engaged in physical activities that would boost their energy requirements. Therefore, this individual may not need specific nutritional interventions solely based on their living situation. Option D, an older, sedentary adult with painful joints, may have a lower metabolic rate due to reduced physical activity levels. While nutritional interventions may still be necessary to support overall health and joint function, this individual is less likely to require the same level of nutritional support as someone with an increased metabolic rate due to illness. Educationally, understanding factors that influence metabolic rate and nutritional needs is crucial in providing appropriate care for individuals with varying health conditions. Recognizing when increased energy demands are present, such as during illness, highlights the importance of tailored nutritional interventions to support optimal health outcomes.

Correct Answer: C

Rationale: In the context of nutrition and fluid balance, the correct answer to the question, "What health problem may occur in a person who is on a low-carbohydrate diet for a long period of time?" is option C) ketosis. Ketosis is a metabolic state that occurs when the body is deprived of carbohydrates and starts to burn fat for energy, leading to the production of ketones. The correct answer is right because a prolonged low-carbohydrate diet can push the body into ketosis, which can have various implications on health. While the body can adapt to using fat for fuel, prolonged ketosis can lead to potential risks such as kidney stones, bad breath, fatigue, and in severe cases, ketoacidosis. Option A) obesity is incorrect because a low-carbohydrate diet is often used for weight loss and can actually help in reducing body fat when followed correctly. Option B) fatigue may occur initially as the body adapts to using fat as fuel, but it is not a long-term health problem associated with low-carb diets. Option D) infection is unrelated to the metabolic changes associated with low-carbohydrate diets. Educationally, understanding the effects of different macronutrients on the body is crucial for making informed dietary choices. It's important to emphasize that while low-carb diets can be effective for weight loss, they should be followed with caution and ideally under the guidance of a healthcare provider to prevent potential health risks like ketosis. Balancing macronutrients and choosing a diet that suits individual needs and lifestyle is key to maintaining overall health and well-being.

Correct Answer: B

Rationale: In the context of healthcare, understanding the term "anorexia" is crucial for effective patient care. The correct answer is B) lack of appetite. Anorexia, in this context, refers to a decreased desire to eat, leading to reduced food intake. This can result from various factors such as illness, medications, psychological distress, or underlying medical conditions. Option A) eating more than daily requirements is incorrect because anorexia is characterized by a reduced appetite and decreased food intake, not excessive eating. Option C) vitamin C deficiency is incorrect as anorexia does not specifically refer to a deficiency in a particular nutrient like vitamin C. Option D) fluid deficit is incorrect as anorexia pertains to a lack of appetite rather than dehydration or fluid imbalance. Educationally, it is important for healthcare professionals to accurately interpret and document terminologies like anorexia to provide appropriate care for their patients. By understanding the correct definition of anorexia, nurses and other healthcare providers can address nutritional concerns, monitor intake, and collaborate with the healthcare team to improve the patient's overall well-being.