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Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL?

A.

Weak quadriceps muscles

B.

Decreased deep tendon reflexes

C.

Tingling of extremities with possible tetany

D.

Light-headedness when standing up

Answer and Explanation

The Correct Answer is C

A. Weak quadriceps muscles can occur with electrolyte imbalances, but the provided values do not indicate hypokalemia or other issues causing muscle weakness.  

 

B. Decreased deep tendon reflexes are generally associated with elevated calcium levels or other electrolyte disturbances but are not specifically indicated by the given lab values.  

 

C. A calcium level of 4.5 mg/dL is significantly low (normal range is typically around 8.5-10.5 mg/dL), which can lead to hypocalcemia symptoms such as tingling of the extremities and tetany due to increased neuromuscular excitability.  

 

D. Light-headedness when standing up (orthostatic hypotension) is more related to fluid volume status or dehydration rather than directly related to the given electrolyte levels.


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Correct Answer is A

Explanation

A. This outcome is specific, measurable, and directly addresses the goal of managing constipation by aiming for a bowel movement.

B. Discontinuing pain medication abruptly may be unrealistic and can cause distress for the patient.

C. Ambulation may help with constipation but does not directly measure or ensure bowel movement.

D. Offering laxatives or stool softeners is an intervention rather than a measurable patient outcome.

Correct Answer is D

Explanation

A. While hospice care is appropriate for those with terminal illnesses, the criteria are more specifically defined by life expectancy rather than just the diagnosis itself.

B. Although pain management is a significant aspect of hospice care, the criteria for eligibility focus on life expectancy rather than need for pain management alone.

C. Completion of an advance directive is encouraged but not a specific criterion for hospice care; patients can receive hospice services without having an advance directive in place.

D. Hospice care is typically designated for patients who are expected to live less than 6 months, focusing on providing comfort and support in the final stages of life.

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