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InstructiоnsReаd eаch questiоn cаrefully.Answer each questiоn by bubbling your answer on the Scantron answer sheet.After you have finished answering all questions, select TRUE.Click Finish Attempt at the bottom of the page.On the next page, click Submit All and Finish.If a confirmation message appears, click Submit All and Finish again to complete your submission.Once your assessment has been submitted successfully, notify your proctor that you are finished. Please wait for the proctor's instructions before proceeding to the next step.PIC Assessment 2 Key/Version A____ 1. A nurse plans care for a client experiencing frequent watery stools related to Clostridium difficile infection. Which nursing intervention is most appropriate for preventing perianal skin breakdown? a. Cleanse the perianal area gently after each bowel movement and apply a moisture-barrier product. c. Apply adhesive dressings over the perianal area to prevent contact with liquid stool. b. Limit perianal cleansing to once per shift to prevent excessive skin irritation. d. Scrub the perianal area with antibacterial soap after each episode of diarrhea. ____ 2. A nurse caring for a client receiving continuous IV crystalloid solution through a peripheral IV notices the tubing has fallen to the floor while repositioning the client. The IV was initiated 72 hours ago, and the tubing was last changed 48 hours ago. Which action demonstrates the nurse's understanding of maintaining IV system integrity and infection prevention? a. Disinfect the contaminated tubing section with alcohol-based 2% chlorhexidine, allow to dry completely, then rehang the tubing and continue the infusion c. Assess the IV site for signs of infection or phlebitis; if assessment is normal, flush the line with 10 mL sterile saline to clear potential contaminants before continuing infusion b. Replace the entire IV administration set immediately using standard aseptic technique, as floor contamination creates unacceptable infection risk regardless of tubing age d. Disconnect the contaminated tubing at the nearest connection point, discard the floor-contaminated section, attach new extension tubing using aseptic technique to minimize system disruption ____ 3. A prenatal nurse provides education to a pregnant client who reports increasing sleep disturbances. Which sleep pattern is commonly associated with the third trimester of pregnancy? a. Complete return to pre-pregnancy sleep patterns as the body adapts to hormonal changes. c. Consistently improved sleep quality because daytime drowsiness decreases throughout pregnancy. b. Increased insomnia and symptoms of restless legs syndrome that may disrupt sleep quality. d. Decreased need for sleep as physiological demands of pregnancy become less significant. ____ 4. A nurse triages a 9-month-old client presenting with 48 hours of fever (103°F) and decreased oral intake. The parent reports only 2 wet diapers in 24 hours versus the usual 6–8. The client weighs 9 kg and appears lethargic with a sunken fontanelle. Which statement best explains why this infant is at particularly high risk for severe fluid and electrolyte imbalances? a. Decreased oral intake combined with fever-induced diaphoresis creates negative fluid balance, while the infant’s developing kidneys retain excessive sodium leading to hypernatremia and cellular dehydration c. The infant’s weight-to-surface-area ratio creates excessive evaporative losses through skin, and prolonged fever depletes glucose stores causing metabolic acidosis that compounds dehydration effects b. Infants have proportionally greater total body water (70–80% body weight) and higher metabolic rate, causing greater water needs; fever increases insensible losses while immature kidneys cannot concentrate urine effectively to conserve water d. Infants’ limited fluid reserves and small circulating blood volume mean even modest losses represent large proportional deficits, while fever suppresses ADH release preventing compensatory water retention ____ 5. A critical care nurse teaches new graduate nurses about fluid distribution between body compartments. Which principle best explains fluid movement between the intravascular and interstitial spaces? a. Aldosterone opens cell membrane channels to rapidly equalize water between intracellular and interstitial spaces. c. Hydrostatic pressure pushes fluid out of capillaries, while plasma oncotic pressure draws fluid back into the vascular space. b. Intracellular fluid moves directly into blood vessels primarily through changes in cardiac output. d. Sodium concentration directly forces plasma proteins from the intravascular space into the interstitial space. ____ 6. A nurse assesses a client with a peripheral IV infusing normal saline. Which finding requires the most immediate nursing intervention? a. The infusion rate has decreased because the IV tubing is kinked under the client’s arm. c. The transparent dressing is slightly lifted along one edge without redness or swelling. b. The client reports mild heaviness in the IV arm with slight edema of the hand. d. The IV site is red, warm, and tender with a palpable venous cord and purulent drainage. ____ 7. A nurse reviews data showing that ICU clients with sepsis have longer hospital stays and poorer outcomes when significant sleep-wake cycle disruptions occur. Which physiological rationale best supports interventions to protect circadian rhythms during critical illness? a. Protecting normal sleep cycles eliminates confusion and suspicious behavior caused by REM deprivation. c. Maintaining normal sleep patterns completely prevents metabolic changes associated with critical illness. b. Preserving the sleep-wake cycle prevents neurological deterioration associated with serious illness. d. Maintaining circadian rhythm coordination supports immune system function needed to fight infection. ____ 8. A trauma client who sustained significant blood loss from a motor vehicle accident arrives in the emergency department hypotensive with decreased urine output. The nurse anticipates aggressive fluid resuscitation. Which physiological process will primarily regulate restoration of the client’s extracellular fluid volume following hemorrhage? a. Increased atrial natriuretic peptide secretion promoting sodium excretion and fluid shift from interstitial space into the vascular compartment c. Antidiuretic hormone release causing increased water reabsorption in the collecting ducts to restore circulating volume independent of sodium retention b. Sympathetic nervous system stimulation causing vasoconstriction and fluid redistribution from intracellular to extracellular compartments d. Activation of the renin-angiotensin-aldosterone system causing sodium and water resorption to increase extracellular fluid volume and restore perfusion ____ 9. A nurse cares for a client with chronic kidney disease whose laboratory results show a pH of 7.32, HCO3? of 18 mEq/L, and elevated serum creatinine. Which renal impairment best explains the client’s metabolic acidosis? a. Increased ammonium excretion causes excessive loss of hydrogen ions through the urine. c. Increased bicarbonate reabsorption causes excessive retention of alkaline substances in the blood. b. Reduced ability of the kidneys to excrete metabolic acids causes hydrogen ions to accumulate in the body. d. Reduced carbon dioxide elimination by the kidneys causes carbonic acid to accumulate in the blood. ____ 10. A 68-year-old client with Parkinson's disease is hospitalized after falling at home during sleep. The spouse reports the client "acts out violent dreams" by punching and kicking during the night, with complete recall of dream content upon awakening. The client has no memory problems during waking hours. Which sleep disorder characteristic is most consistent with this presentation? a. Confusional arousal from NREM sleep, characterized by disorientation and complex motor behaviors during slow-wave sleep with amnesia for the events c. Sleep-related movement disorder manifesting as periodic limb movements during REM sleep, causing injury risk due to repetitive stereotyped kicking motions b. REM sleep behavior disorder, characterized by loss of normal REM atonia allowing dream enactment with detailed dream recall, commonly associated with neurodegenerative diseases d. Parasomnia overlap disorder combining sleepwalking and sleep terrors, resulting in violent behaviors during transitions between sleep stages with partial dream recall ____ 11. A nursing supervisor notes that clients in a memory care unit who nap frequently during daytime hours demonstrate increased confusion and agitation during evening hours. Staff report clients often sleep only 4–5 total hours at night despite being in bed for 8–9 hours. Which explanation based on sleep cycle stages best accounts for these observations? a. Daytime napping reduces homeostatic sleep drive, causing difficulty initiating and maintaining nighttime sleep cycles, resulting in insufficient slow-wave stage 3 sleep needed for cognitive restoration c. Multiple naps alter the typical 90-minute sleep cycle duration, compressing cycles so clients complete them too quickly and wake after only 4–5 hours thinking they've had full sleep b. Frequent napping fragments the normal four-to-six cycle progression, preventing clients from reaching adequate REM sleep that processes emotional content and reduces behavioral symptoms d. Daytime sleep interferes with the normal progression from stage 1 to stage 3 NREM sleep, causing clients to remain in lighter sleep stages throughout the night with frequent arousals ____ 12. A nurse prepares to initiate a blood transfusion for a postoperative client. After retrieving the packed red blood cells from the blood bank, two nurses verify the blood product identification, perform bedside client identification using two identifiers, and confirm ABO/Rh compatibility. Which action should the nurse implement immediately before initiating the transfusion? a. Perform a complete physical assessment focusing on cardiopulmonary status, review the client's pretransfusion type and screen results, and ensure emergency medications are readily available before connecting the blood c. Flush the existing peripheral IV with 10 mL normal saline to confirm patency, spike the blood bag with filtered tubing, and begin infusion at 50 mL/hr while monitoring for immediate reactions b. Prime the blood administration set with normal saline, obtain baseline vital signs (temperature, pulse, respirations, blood pressure), and initiate the transfusion at 2 mL/min for the first 15 minutes while remaining at bedside d. Verify the client has signed informed consent for transfusion, check that IV access is 20-gauge or larger, and educate the client about signs of transfusion reactions to report during infusion ____ 13. A nurse reviews laboratory results for a client with acute kidney injury. The serum potassium is 6.8 mEq/L, and the ECG shows tall peaked T waves and widened QRS complexes. Which complication of hyperkalemia requires the most immediate nursing attention? a. Paresthesias resulting from changes in nerve and muscle cell membrane function. c. Progressive muscle weakness caused by decreased neuromuscular excitability. b. Life-threatening cardiac dysrhythmias that may progress to ventricular fibrillation and cardiac arrest. d. Reduced renal potassium excretion associated with decreased kidney function. ____ 14. A nurse assesses a client with severe vomiting and diarrhea for three days. Laboratory results show sodium 128 mEq/L (normal 136-145), decreased extracellular fluid volume, and increased urine osmolality despite low serum osmolality. Which compensatory process best explains the body's attempt to regulate electrolyte and fluid balance in this client? a. The renin-angiotensin-aldosterone system is activated by decreased renal perfusion, causing aldosterone release that promotes sodium and water reabsorption to restore extracellular fluid volume c. Atrial natriuretic peptide secretion increases due to volume depletion, promoting sodium retention while increasing water excretion to concentrate remaining extracellular fluid b. The kidneys activate vitamin D to enhance intestinal sodium absorption while simultaneously decreasing sodium excretion to compensate for gastrointestinal losses d. Antidiuretic hormone is released in response to volume depletion despite low serum osmolality, prioritizing volume restoration over osmolality correction by retaining water ____ 15. A client returns for a 4-week follow-up after implementing sleep-hygiene practices for chronic insomnia. The client reports going to bed at 10 PM nightly, falling asleep within 20 minutes, waking once during the night, and sleeping approximately 7 hours total. However, the client states, “I still feel tired during the day sometimes.” Which evaluation indicates successful therapy outcomes? a. The therapy is ineffective because the client’s subjective report of daytime tiredness indicates sleep quality remains poor despite objective improvements in sleep pattern measurements c. The therapy is effective because the client demonstrates improved sleep latency, reduced awakenings, and adequate sleep duration compared to baseline, with daytime fatigue likely unrelated to sleep b. The therapy requires modification because single nighttime awakening and occasional daytime fatigue suggest the client needs pharmacological intervention added to sleep-hygiene measures d. The therapy is partially effective because while sleep quantity has improved to 7 hours, persistent daytime fatigue indicates the expected outcome of feeling rested upon awakening has not been met ____ 16. A nurse develops a care plan for a client with Risk for Impaired Skin Integrity related to persistent diarrhea from Clostridium difficile infection. Which expected outcome is most appropriate? a. Any skin breakdown will completely heal within 24 hours of initiating nursing interventions. c. The client will report no perianal discomfort within 8 hours based solely on a pain rating. b. The client will maintain intact perianal skin throughout hospitalization, as evaluated by daily skin assessment. d. The client’s diarrhea will completely resolve within 48 hours, as measured by stool frequency. ____ 17. A nurse teaches a community class about insomnia. Which characteristic best differentiates transient insomnia from chronic insomnia? a. Transient insomnia is commonly associated with a temporary situational stressor and usually improves when the stressor resolves or the person adapts. c. Chronic insomnia occurs only when a person experiences depression or anxiety for an extended period. b. Chronic insomnia and transient insomnia have the same duration and differ only in the severity of daytime symptoms. d. Transient insomnia requires sedative-hypnotic medication, whereas chronic insomnia responds to relaxation techniques alone. ____ 18. A school nurse consults with administrators about starting high school classes at 8:30 AM instead of 7:15 AM after data shows students average only 6 hours of sleep nightly with declining academic performance. A board member argues, “Teenagers just need to go to bed earlier—they need the same 7–8 hours adults need.” How should the nurse respond? a. "While adolescents and adults both need approximately 7–8 hours, teenagers' biological clocks shift later, so early start times create sleep deprivation regardless of bedtime" c. "Teenagers require the same sleep duration as adults, but they need more REM sleep for brain development, which only occurs with later wake times" b. "Adolescents actually require 8–10 hours of sleep nightly, significantly more than the 7–8 hours adults need, making the current schedule inadequate for their developmental needs" d. "Adolescents need less total sleep than adults but higher quality sleep; the issue is sleep disruption from technology use, not the school schedule" ____ 19. A nurse assesses a peripheral IV site with a transparent semipermeable membrane dressing applied 5 days ago. The dressing edges are lifting, and moisture is visible underneath. Which action should the nurse take first? a. Wait until the routine dressing-change interval because transparent dressings remain effective for 7 days. c. Change the dressing immediately using aseptic technique because its integrity is compromised. b. Reinforce the lifting edges with nonsterile tape and continue routine site monitoring. d. Leave the dressing in place because the IV site has no redness, swelling, or tenderness. ____ 20. A home health nurse assesses an older adult who reports vivid, frightening dreams that cause him to physically strike out during sleep. The client has Parkinson’s disease and recently injured his spouse during an episode. Which assessment finding most strongly supports REM sleep behavior disorder? a. The episodes occur during NREM stage 3 and are followed by complete amnesia. c. The client awakens easily after the episode and recalls the vivid dream content in detail. b. The episodes occur primarily during the first hour after falling asleep and involve slow-wave sleep. d. The client experiences significant confusion and has no memory of the event after awakening. ____ 21. A parent reports their adolescent client sleeps until noon on weekends but struggles to wake for school at 6:30 AM on weekdays, resulting in chronic fatigue and poor academic performance. The teen goes to bed around 11 PM nightly. Which explanation of sleep regulation mechanisms should guide the nurse's response? a. Teenagers experience a natural circadian rhythm shift toward later sleep and wake times, creating misalignment between their biological clock and early school schedules c. Adolescents require more total sleep than adults due to increased growth hormone secretion during NREM stage 3, making early school start times developmentally inappropriate b. The homeostatic sleep drive (Process S) accumulates more rapidly in adolescents, creating excessive sleepiness that requires extended sleep periods to resolve adequately d. The reticular activating system in adolescents responds less effectively to morning arousal stimuli, requiring gradual adjustment through consistent wake times including weekends ____ 22. A nurse assesses a postoperative client receiving continuous IV normal saline at 125 mL/hr for 36 hours. Assessment reveals crackles in bilateral lung bases, peripheral edema +2, jugular venous distention, dyspnea with exertion, and weight gain of 3 kg since admission. The nurse identifies multiple nursing diagnoses. Which diagnosis requires priority intervention based on clinical judgment? a. Risk for Decreased Cardiac Output related to increased preload and myocardial workload from volume expansion exceeding cardiac capacity c. Excess Fluid Volume related to excessive IV fluid administration as evidenced by peripheral edema, weight gain, and positive fluid balance b. Anxiety related to breathing difficulty as evidenced by dyspnea with exertion and expressed concern about worsening symptoms d. Impaired Gas Exchange related to pulmonary congestion as evidenced by crackles, dyspnea, and decreased oxygen saturation from fluid overload ____ 23. A postoperative client on a medical-surgical unit complains of inability to sleep despite receiving pain medication. The nurse observes the room temperature is 78°F, hallway conversations are audible, and the client’s roommate snores loudly. The client states, “At home I always sleep with my wife and keep the TV on for background noise.” Which factor is most likely the primary sleep disruptor? a. The lack of television background noise, as the absence of familiar environmental sounds disrupts the client’s established sleep routine and circadian rhythm c. The hallway noise and roommate’s snoring, as unfamiliar and loud hospital noises are the greatest sleep disruptors during the first night of hospitalization b. The room temperature of 78°F, as a room that is too warm causes restlessness and prevents the body from achieving the temperature drop needed for sleep d. The absence of the client’s usual bed partner, as sleeping alone causes wakefulness when a person typically sleeps with another individual ____ 24. A nurse develops a care plan for a client receiving chemotherapy who is at risk for tumor lysis syndrome. Which intervention is the priority for detecting potentially life-threatening complications? a. Limit oral fluid intake to reduce the risk of additional electrolyte shifts. c. Perform frequent cardiac monitoring and assess serum potassium, phosphate, calcium, and uric acid levels. b. Encourage increased intake of potassium-rich foods to prevent electrolyte depletion. d. Maintain strict bed rest to reduce metabolic demands and prevent electrolyte changes. ____ 25. A nurse assesses a client’s peripheral IV site initiated 48 hours ago and notes redness along the vein path extending 2 inches above the insertion site, warmth, pain rated 4/10, and slight swelling. The infusion is running at the prescribed rate with no resistance. Which action should the nurse implement first? a. Discontinue the IV immediately, document phlebitis assessment findings using a standardized scale, and initiate a new peripheral IV in a different site on the opposite extremity c. Stop the infusion immediately, discontinue the IV catheter, apply a warm compress to the site, and initiate a new IV in the opposite extremity using a larger gauge catheter b. Leave the current IV in place to maintain venous access, notify the provider for orders to change the infusion solution to a less irritating alternative, and administer prescribed anti-inflammatory medication d. Slow the IV infusion rate by 50%, apply a warm compress to the affected area, elevate the extremity, and reassess the site in 1 hour for symptom progression ____ 26. A nurse evaluates outcomes for a family caregiver who received sleep-promotion interventions 6 weeks ago for insomnia related to caregiving stress. Which finding best indicates that the interventions have been effective? a. The caregiver attends one caregiver support group meeting during the evaluation period. c. The caregiver continues to record daily sleep patterns in a sleep log. b. The caregiver exercises three times weekly as part of the recommended sleep-hygiene plan. d. The caregiver reports feeling more rested upon awakening and emotionally prepared to provide care. ____ 27. A nurse assesses a client with diabetic ketoacidosis who has rapid, deep respirations (Kussmaul breathing). Arterial blood gas results show pH 7.28, PaCO 8 mmHg, and HCO- 14 mEq/L. Which statement best explains the respiratory system's role in regulating this client's acid-base balance? a. The lungs are compensating for metabolic acidosis by increasing ventilation to excrete excess carbonic acid, lowering PaCO and shifting pH toward normal c. The lungs are attempting to correct respiratory acidosis by eliminating accumulated CO from inadequate ventilation, but metabolic acid production is overwhelming this mechanism b. The lungs are correcting metabolic acidosis by producing additional bicarbonate through enhanced gas exchange, which will restore normal pH when renal function stabilizes d. The lungs are responding to decreased blood pH by retaining carbonic acid through hypoventilation, but the client's compensatory mechanism is failing due to severe acidosis ____ 28. A nurse begins a sleep assessment with a 58-year-old client who mentions "not sleeping well lately." The client appears hesitant to elaborate and states, "I don't want to complain—everyone has trouble sleeping sometimes." Which initial interview approach best demonstrates client-centered assessment of the sleep problem? a. Use open-ended questions like "Tell me more about your sleep" to allow the client to describe the problem fully before asking focused follow-up questions c. Reassure the client that sleep problems are common and then provide a standardized sleep questionnaire for the client to complete independently b. Acknowledge the client’s concern about complaining and move to other health history topics, returning to sleep assessment only if the client raises concerns again d. Ask specific closed-ended questions about sleep duration, bedtime, and wake time to quickly establish whether the client meets diagnostic criteria for a sleep disorder ____ 29. A community health nurse assesses a 79-year-old client who takes furosemide and frequently uses over-the-counter laxatives. Which finding places the client at greatest risk for hypokalemia? a. Age-related reduction in total body water and renal concentrating ability. c. Concurrent potassium loss from furosemide therapy and frequent laxative use. b. Decreased dietary intake associated with a reduced appetite. d. Sodium and water retention associated with chronic heart failure. ____ 30. An ICU implements a protocol to improve sleep quality for clients with sepsis after research shows that sleep deprivation is associated with poorer outcomes. Which physiological function of sleep is most directly relevant to recovery from sepsis? a. Sleep completely prevents protein catabolism and loss of muscle mass during critical illness. c. Sleep prevents cardiovascular changes by maintaining a constant heart rate and blood pressure. b. Sleep primarily promotes procedural memory needed to understand complex treatment regimens. d. Sleep supports immune system function needed to fight infection and regulate inflammatory responses. ____ 31. A hospitalized client reports difficulty sleeping. Which question should the nurse ask first to establish the client’s usual sleep-wake pattern? a. “What time do you usually go to bed at night, and what time do you typically wake up in the morning?” c. “What temperature and lighting conditions do you prefer in your bedroom?” b. “How many times do you usually awaken during the night?” d. “What medications, herbs, or supplements do you use to help you sleep?” ____ 32. A postoperative client on POD 2 reports sleeping only 2–3 hours nightly due to pain and frequent interruptions. The nurse notes the client appears confused during morning assessment, has difficulty following instructions, and demonstrates poor balance when ambulating. Which physiological effect of sleep-wake cycle disruption best explains these findings? a. Disrupted circadian rhythm affects coordination of body temperature regulation and neurological function, causing the confusion and impaired motor performance c. Loss of REM sleep causes protein catabolism and negative nitrogen balance, impairing wound healing and cognitive function during the recovery period b. Sleep deprivation alters immune function and inflammatory responses, leading to increased pain sensitivity that affects mental status and physical stability d. Inadequate sleep causes mood disturbances and decreased motivation, resulting in the client's apparent confusion and reluctance to follow mobility instructions ____ 33. A surgical nurse notes that clients on the unit who report sleeping poorly (less than 4 hours nightly) have significantly delayed wound healing compared to those sleeping 7–8 hours. Laboratory results show the sleep-deprived clients have lower albumin levels and negative nitrogen balance. Which sleep function best explains these findings? a. Sleep deprivation reduces growth hormone secretion during slow-wave sleep, impairing the anabolic processes necessary for protein synthesis and tissue repair c. Sleep loss causes protein catabolism and negative nitrogen balance, reducing the amino acid availability essential for wound healing and tissue regeneration b. Poor sleep quality impairs metabolic regulation, causing hyperglycemia that damages microvascular circulation and impedes oxygen delivery to healing wounds d. Inadequate sleep disrupts immune function, leading to increased inflammatory cytokine production that interferes with collagen deposition and wound closure ____ 34. A nurse evaluates the effectiveness of interventions for a client at risk for impaired skin integrity related to persistent diarrhea. Which finding best indicates that the desired outcome has been achieved? a. The client reports mild discomfort during perianal cleansing after bowel movements. c. The perianal skin remains intact without redness, excoriation, or evidence of breakdown. b. The client reports that the frequency of bowel movements has decreased slightly. d. The client requires assistance with hygiene following episodes of diarrhea. ____ 35. A postoperative orthopedic client reports inability to sleep despite receiving PRN opioid pain medication 2 hours ago (pain now 3/10). The nurse observes the client is positioned with the operative leg flat, compression stockings are wrinkled, the surgical dressing has minimal drainage but edges are curling and pulling at the skin, and the room temperature is 72°F. Which intervention most directly addresses comfort factors disrupting sleep? a. Lower the room temperature to 68°F and provide an extra blanket, as postoperative clients often experience temperature dysregulation affecting sleep c. Administer an additional dose of pain medication since the current pain level of 3/10 still interferes with the client’s ability to relax and fall asleep b. Assess for bladder distention and offer toileting assistance, as urinary retention commonly develops postoperatively and prevents comfortable sleep d. Reposition the client to elevate the operative extremity on pillows, smooth the compression stockings, and reinforce dressing edges with hypoallergenic tape ____ 36. A nurse receives laboratory results showing serum potassium of 6.4 mEq/L for a client with chronic kidney disease. The client is alert and denies symptoms. Which assessment should the nurse prioritize immediately to evaluate for life-threatening complications? a. Deep tendon reflex testing and muscle strength assessment to identify neuromuscular hyperexcitability and progression toward flaccid paralysis c. Hourly urine output measurement to determine kidney function and potassium excretion capability before administering emergency medications b. Continuous cardiac monitoring to detect peaked T waves, widened QRS complexes, or dysrhythmias indicating cardiac conduction abnormalities from hyperkalemia d. Serial blood pressure measurements in supine and sitting positions to detect orthostatic hypotension from impaired vascular smooth muscle function ____ 37. A client admitted with prolonged vomiting for 5 days presents with muscle weakness, abdominal distention, and hypoactive bowel sounds. ECG shows flattened T waves and prominent U waves. Serum potassium is 2.8 mEq/L (normal 3.5–5.0). Which pathophysiological understanding guides the nurse's priority interventions? a. Prolonged vomiting depletes hydrochloric acid, triggering compensatory aldosterone release that increases renal potassium excretion, compounding the hypokalemia and requiring both fluid and potassium replacement c. Gastric fluid loss decreases extracellular volume, activating RAAS and increasing aldosterone secretion that promotes urinary potassium wasting while attempting to restore volume b. Vomiting removes potassium-rich gastric contents while triggering stress response that releases catecholamines, driving potassium into cells and masking the true severity of depletion d. Vomiting causes direct potassium loss from gastric secretions combined with metabolic alkalosis that shifts potassium intracellularly, creating total body potassium depletion requiring aggressive IV replacement ____ 38. A client with a traumatic brain injury affecting the hypothalamus demonstrates irregular sleep-wake patterns, sleeping briefly at random times throughout the day and night. Which disruption best explains the loss of a predictable circadian sleep-wake rhythm? a. Loss of prostaglandin production eliminates the homeostatic drive responsible for initiating sleep. c. Injury to the suprachiasmatic nucleus disrupts the biological clock that coordinates circadian sleep-wake timing. b. Impaired hypocretin secretion prevents the normal progression through all stages of sleep. d. Damage to the reticular activating system permanently prevents the maintenance of wakefulness. ____ 39. A nurse assesses a client with a serum sodium level of 118 mEq/L who reports headache and nausea and appears confused. Which assessment is the priority for determining the severity of the client’s hyponatremia? a. Assess skin turgor and mucous membranes for evidence of extracellular fluid volume deficit. c. Measure intake and output to identify patterns contributing to the sodium imbalance. b. Perform frequent neurological assessments for changes in level of consciousness, orientation, and seizure activity. d. Monitor deep tendon reflexes for evidence of neuromuscular hyperexcitability. ____ 40. A nurse assesses a patient with severe vomiting and diarrhea for three days. Laboratory results show sodium 128 mEq/L (normal 136-145), decreased extracellular fluid volume, and increased urine osmolality despite low serum osmolality. Which compensatory process best explains the body's attempt to regulate electrolyte and fluid balance in this patient? a. The renin-angiotensin-aldosterone system is activated by decreased renal perfusion, causing aldosterone release that promotes sodium and water reabsorption to restore extracellular fluid volume c. Antidiuretic hormone is released in response to volume depletion despite low serum osmolality, prioritizing volume restoration over osmolality correction by retaining water b. Atrial natriuretic peptide secretion increases due to volume depletion, promoting sodium retention while increasing water excretion to concentrate remaining extracellular fluid d. The kidneys activate vitamin D to enhance intestinal sodium absorption while simultaneously decreasing sodium excretion to compensate for gastrointestinal losses
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