Electrolytes Question #22

Question

An older client with heart failure and a serum sodium level of 113 mEq/L is demonstrating aggressive behavior and does not recognize family members. Which response should the nurse make when the family expresses concern about the client?

Answers

  1. "The client may be experiencing dementia, and the hospitalization has worsened the confusion."
    • Rationale:
  2. "Most older adults get confused in the hospital."
    • Rationale:
  3. "The sodium level is low, and the confusion will resolve as the levels normalize."
    • Rationale:
  4. "The sodium level is high and the behavior is a result of dehydration."
    • Rationale:

Overview

Explanation

The correct answer is C. A normal serum sodium level is 135 to 145 mEq/L. Neurological symptoms occur when sodium level falls below 120 mEq/L. The confusion is an acute condition that will resolve as the sodium level normalizes. Dementia is an irreversible condition.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale