A client's serum potassium level is approaching 7 mEq/L. Which physical assessment would the nurse prioritize based on this serum lab value?

Cardiac

Gastrointestinal

Respiratory

Neurologic

Answer and Explanation

The Correct Answer is A

A. Hyperkalemia can have significant cardiac effects, potentially leading to life-threatening arrhythmias such as bradycardia, heart block, ventricular tachycardia, or ventricular fibrillation. As potassium levels rise, it affects the electrical conduction of the heart, leading to changes in the ECG (electrocardiogram) and potentially causing fatal arrhythmias.

B. While hyperkalemia primarily affects the cardiovascular system, gastrointestinal symptoms can also occur. These may include nausea, vomiting, abdominal pain, and diarrhea. However, these symptoms are typically less severe compared to cardiac manifestations. Monitoring for gastrointestinal symptoms helps in assessing overall clinical status but is not as critical as assessing cardiac function in the context of hyperkalemia.

C. Respiratory symptoms are not typically associated with hyperkalemia unless severe acid-base disturbances are present. Potassium imbalance itself does not directly affect respiratory function. Therefore, while it is important to assess respiratory status in any client, it is not the priority in the context of hyperkalemia.

D. Hyperkalemia can affect the nervous system, leading to symptoms such as muscle weakness, tingling sensations, and even paralysis in severe cases. However, neurologic symptoms usually occur at higher potassium levels or in the presence of significant electrolyte imbalances affecting nerve function.

Monitoring for neurologic symptoms is important but is generally secondary to assessing cardiac status in the context of approaching severe hyperkalemia.

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Correct Answer is C

Explanation

A. Intractable pain refers to pain that is severe and persistent, difficult to control or manage despite treatment. It may be constant or intermittent but is generally not specific to a body part that has been amputated. Intractable pain is not typically used to describe pain specifically related to a phantom limb or residual limb pain after amputation.

B. Radiating pain is pain that spreads from its origin to another location in the body. It often follows the path of a nerve and can be associated with nerve compression or irritation. While radiating pain can occur in various conditions, it does not specifically describe the type of pain experienced in an amputated limb.

C. Phantom pain is perceived pain that feels like it is coming from a part of the body that has been amputated. It is a common phenomenon after limb amputation where the brain continues to receive pain signals from nerves that originally innervated the missing limb. Phantom pain is the correct term for the pain experienced by a client with a below-the-knee amputation who complains of pain in the right ankle. It is described as constant pain in the missing limb or part.

D. Referred pain is pain perceived at a location other than the site of the painful stimulus or origin. It occurs because of shared neural pathways between different areas of the body. Referred pain is not typically used to describe pain specifically related to amputation or phantom limb pain.

A. Stage IV B. Stage II C. Stage III D. Unstageable

Correct Answer is D

Explanation

D. Unstageable pressure injuries are covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed, making it difficult to determine the depth of tissue damage. If the wound over the sacrum is covered with dark, hard tissue that makes it impossible to visualize the depth of the wound, it could be considered unstageable

A. The description of tissue over the sacrum being dark, hard, and adherent to the wound edge suggests extensive tissue damage and possibly involvement of deeper structures like muscle or bone.

B. Stage II pressure injuries involve partial-thickness loss of skin with exposed dermis. These wounds are shallow and typically present as abrasions, blisters, or shallow ulcers.

C. Stage III pressure injuries involve full-thickness skin loss with visible adipose (fat) tissue in the ulcer. These wounds may also have undermining or tunneling.

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A client's serum potassium level is approaching 7 mEq/L. Which physical assessment would the nurse prioritize based on this serum lab value?

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Naxlex Comprehensive Predictor Exams

A client who has had a right-sided below-the-knee amputation is complaining of constant pain in his right ankle. The nurse documents that the client is experiencing what type of pain?

Correct Answer is C

Explanation

The nurse observes that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the stage for this pressure injury?

Correct Answer is D

Explanation

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