Medical Surgical Sodium Na+ #11

Question

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

Answers

  1. "Most older adults get confused in the hospital."
    • Rationale:

      This answer is not correct because while many older adult clients may experience some confusion when hospitalized, this is not an accurate response to the family based on the current data. This client is confused due to hyponatremia.

  2. "The sodium level is high and the behavior is a result of dehydration."
    • Rationale:

      This answer is not correct because this client’s serum sodium level indicates hyponatremia, not hypernatremia. Clinical manifestations of hyponatremia include confusion, fatigue, headache, and nausea.

  3. "The sodium level is low, and the confusion will resolve as the levels normalize."
    • Rationale:

      This answer is correct because 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.

  4. "The client may be experiencing dementia, and the hospitalization has worsened the confusion."
    • Rationale:

      This answer is not correct because dementia is an irreversible condition and is not the cause of the client’s confusion; therefore, this is not an accurate response by the nurse.

Overview

The normal range for serum sodium levels is 135 to 145 mEq/L. Clinical manifestations of hyponatremia include confusion, fatigue, headache, and nausea.

Explanation

Learning Outcomes

A serum sodium level of 113 mEq/L indicates the client is experiencing hyponatremia (i.e., low serum sodium level). Clinical manifestations of hyponatremia include confusion, fatigue, headache, and nausea. Treatment often depends on the severity and can include limiting fluid intake and medication administration. Therefore, an accurate response to the client’s family concern is, “The sodium level is low, and the confusion will resolve as the levels normalize.”

Test Taking Tip

Consider each response as true or false given the current clinical scenario. The response that is true is the correct answer choice for this question.

Video Rationale