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

Answer and Explanation

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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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.

A. Eat a diet high in carotene. B. Wear prescription glasses. C. Avoid frequent eye pressure measurements. D. Maintain prescribed eye drop regimen

Correct Answer is D

Explanation

A. Eat a diet high in carotene:
While a healthy diet is important for overall well-being, there is no evidence to suggest that a diet high in carotene specifically prevents or treats glaucoma. The focus in glaucoma management is on intraocular pressure control.

B. Wear prescription glasses:
Prescription glasses may be beneficial for addressing refractive errors, but they do not specifically address the management of glaucoma. The client's concern about driving through a tunnel is more likely related to changes in peripheral vision associated with glaucoma.

C. Avoid frequent eye pressure measurements:
This is not the most important instruction. Monitoring intraocular pressure is a crucial aspect of glaucoma management, and the frequency of measurements is determined by the healthcare provider. Regular monitoring helps assess the effectiveness of treatment and disease progression.

D. Maintain the prescribed eye drop regimen:
This is the correct answer. The most important instruction for the client is to adhere to the prescribed eye drop regimen. Medications, often in the form of eye drops, are commonly used to lower intraocular pressure and manage glaucoma. Consistent use of prescribed medications is critical for controlling the condition and preventing further vision loss.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

An adult who was recently diagnosed with glaucoma tells the nurse, "it feels like I am driving through a tunnel." The client expresses great concern about going blind. Which nursing instruction is most important for the nurse to provide this client?

Correct Answer is D

Explanation

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