A client is being treated for chronic kidney disease (CKD). On examination, the client has an elevated blood pressure (BP) and is exhibiting changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?
Use a cushion when sitting.
Perform range of motion exercises.
Document abdominal girth.
Weigh every morning.
The Correct Answer is D
This is the best intervention for the PN to implement because it monitors the client's fluid status and helps detect fluid overload, which can cause hypertension and neurological changes. The PN should weigh the client at the same time, on the same scale, and with the same clothing every day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is the finding that the PN should report to the charge nurse because it indicates a possible complication of Guillain-Barre syndrome, which is autonomic dysfunction. This can affect the cardiac, respiratory, and gastrointestinal systems and cause life-threatening problems such as arrhythmias, hypotension, or respiratory failure. The PN should monitor the client's vital signs closely and report any abnormal changes.
Correct Answer is ["B","D","E"]
Explanation
A) Incorrect - Hyperglycemia typically does not lead to weight loss. In fact, it can result in weight gain due to the body's inability to properly use glucose for energy.
B) Correct - Hyperglycemia can lead to an increased sensation of hunger as the body's cells are not effectively receiving the glucose they need for energy, causing the person to feel hungry.
C) Incorrect - Cool and clammy skin are not typical symptoms of hyperglycemia. Hyperglycemia can lead to dry skin, but it does not cause cool and clammy skin.
D) Correct - Hyperglycemia often leads to increased thirst and urination. Excess glucose in the blood can cause the kidneys to work harder to filter and eliminate the glucose, leading to increased fluid intake and subsequently increased urination.
E) Hyperglycemia can cause dehydration, leading to dry, flushed skin and sometimes headaches due to electrolyte imbalances and reduced blood flow to the brain.
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