A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
Initiate cardiac telemetry.
Administer a PRN dose of a laxative.
Implement seizure precautions
Begin straining all urine
The Correct Answer is D
A. Initiate cardiac telemetry:
Cardiac telemetry is not the immediate priority in this case. Kidney stones are more likely to cause severe localized pain rather than cardiac-related symptoms.
B. Administer a PRN dose of a laxative:
Laxatives are not indicated for the management of kidney stones or the associated flank pain. The priority is to address the specific needs related to the possible passage of kidney stones.
C. Implement seizure precautions:
Seizure precautions are not relevant to the sudden onset of severe flank pain in the context of hyperparathyroidism. The focus should be on managing pain, assessing for kidney stone passage, and addressing the underlying cause.
D. Begin straining all urine.
Straining all urine allows for the collection and examination of any passed stones. This information is important for identifying the composition of the stones and guiding further management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
A. Skin elasticity:
Assessing skin elasticity is a measure of hydration status. Improved skin turgor may suggest that the client is responding positively to diuretic therapy by eliminating excess fluid. However, this may not be as immediate or specific as other indicators of response.
B. Urinary output:
Monitoring urinary output is crucial when administering diuretics like furosemide. Increased urine output indicates that the diuretic is promoting the elimination of excess fluid from the body, which is a desired effect in managing heart failure and fluid overload.
C. Oxygen saturation:
Assessing oxygen saturation is important in monitoring respiratory status. Improvement in oxygen saturation levels indicates that the client is responding to interventions aimed at relieving respiratory distress, such as the administration of furosemide.
D. Lung sounds:
Monitoring lung sounds is a key aspect of assessing respiratory function. Reduction in wheezes and crackles suggests that the diuretic is helping to alleviate pulmonary congestion and fluid accumulation in the lungs, contributing to improved respiratory function.
E. Pain scale:
Assessing pain is relevant if the client has reported chest pain or discomfort associated with heart failure. Reduction in pain may indicate improved cardiac function and response to treatment. However, it's important to note that pain assessment may not be as specific to the effects of furosemide as other respiratory and fluid status indicators.
Correct Answer is C
Explanation
A. Hyperactive bowel sounds.
Hyperactive bowel sounds are more suggestive of gastrointestinal issues, such as intestinal hypermotility or increased peristalsis. While diabetes can affect the gastrointestinal system, hyperactive bowel sounds are not a specific indicator of the symptoms described by the client.
B. Anxiety and sighing.
Anxiety and sighing are more indicative of emotional or psychological factors rather than dehydration. While stress can impact blood sugar levels in individuals with diabetes, anxiety and sighing are not direct signs of the dehydration that may be associated with the reported symptoms.
C. Dark yellow urine.
Dark yellow urine can be a sign of concentrated urine, suggesting dehydration. In diabetes, especially when blood sugar levels are elevated, increased urine production (polyuria) can lead to dehydration. Dark yellow urine may indicate that the urine is more concentrated due to a lack of fluid intake.
D. Myalgia in wrists and hands.
Myalgia in the wrists and hands is not a typical symptom of dehydration related to diabetes. It could be associated with various conditions, such as musculoskeletal issues or nerve-related problems. This symptom is less likely to be directly linked to the reported weakness and palpitations.
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