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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 D

Explanation

A. The belief tool typically involves assessing specific beliefs but does not encompass the broader scope of spiritual well-being.

B. The FICA assessment tool focuses on Faith, Importance, Community, and Address, but it is not characterized by a lengthy questionnaire.

C. The Hope scale assesses a patient's sense of hope but does not specifically address spirituality in depth.

D. The spiritual well-being scale includes multiple questions that explore various aspects of spirituality, including the relationship with God and life purpose, making it the most appropriate choice for this assessment.

Correct Answer is A

Explanation

A. The P wave represents atrial depolarization, which is initiated by the SA node, the heart's natural pacemaker.

B. The AV node is responsible for conducting impulses from the atria to the ventricles but does not initiate the P wave.

C. The Bundle of His transmits the electrical impulses to the ventricles but is not directly associated with the P wave.

D. Purkinje fibers are involved in ventricular depolarization, which corresponds to the QRS complex, not the P wave.

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