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 B
Explanation
A. Carcinogens are substances that contain cancerous cells:
This statement is incorrect. Carcinogens are substances that have the potential to cause cancer, but they do not necessarily contain cancerous cells themselves.
B. Substances that change a cell so that it becomes cancerous are potential sources of cancer:
This is the correct answer. Carcinogens are agents that can induce changes in the genetic material of cells, leading to the development of cancer. They can initiate or promote the process of carcinogenesis.
C. Environmental factors such as sunlight and chemicals can cause cancer to spread:
This statement is not accurate. Carcinogens can contribute to the initiation or promotion of cancer, but the spread of cancer (metastasis) involves complex biological processes and is not directly caused by environmental factors.
D. Carcinogens are in the environment and cannot be avoided:
This statement is not accurate. While carcinogens may be present in the environment, efforts can be made to minimize exposure and adopt preventive measures. Avoidance of known carcinogens and the promotion of a healthy lifestyle can contribute to cancer prevention.
Correct Answer is C
Explanation
A. Begin continuous observation for transient episodes of neurologic dysfunction:
While continuous observation is important, the priority is to notify the stroke team for immediate assessment and management.
B. Place an indwelling urinary catheter and measure strict intake and output:
Monitoring intake and output is an important aspect of nursing care, but it is not the immediate priority when the client is presenting with signs and symptoms suggestive of a stroke.
C. Notify the stroke team to assist with acute assessment and management.
The client's symptoms, including an uneven smile with facial droop to the right side, weaker hand grasp strength on the right, and sudden, severe headache, are indicative of potential stroke symptoms. Quick notification of the stroke team is crucial to facilitate a rapid and comprehensive assessment. Time is a critical factor in the management of stroke, and prompt intervention can improve outcomes.
D. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment:
While positioning is important for maintaining physiological stability, it is not the immediate priority in the context of a potential stroke. Notifying the stroke team for rapid assessment and intervention takes precedence.
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