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.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Measure the client's blood pressure:
While monitoring blood pressure is an important aspect of assessing a client's overall condition, it is not the immediate priority in a suspected opioid overdose. Respiratory depression and difficulty in arousing are more critical concerns that warrant prompt intervention with naloxone.
B. Remove all of the morphine patches:
While eventually, the nurse will need to address the presence of multiple morphine patches, removing them is not the first action. Administering naloxone to reverse the opioid effects takes precedence over patch removal.
C. Apply oxygen per face mask:
While providing oxygen may be necessary to support respiratory function, it doesn't address the underlying cause of the respiratory distress, which is likely opioid toxicity. Administering naloxone is the more direct and immediate intervention to counteract the effects of the opioids.
D. Administer a narcotic antagonist:
This is the correct and immediate priority. If the client is difficult to arouse and has multiple morphine patches, it raises concerns about opioid toxicity. Naloxone is a narcotic antagonist that can reverse the effects of opioid overdose, particularly respiratory depression, and is crucial in this scenario to restore normal respiratory function.
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