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A nurse is caring for a 58-year-old client admitted with reports of increased urination and thirst.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client's 
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}

Sodium level: The client's sodium level is significantly elevated (157 mEq/L), indicating hyponatremia. This is a critical finding that needs to be addressed promptly to prevent serious complications such as seizures and coma.

Heart rate: While the heart rate is slightly elevated, it is not as urgent a concern as the sodium level. Once the sodium level is stabilized, the nurse can address the heart rate if it remains elevated.


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Related Questions

Correct Answer is D

Explanation

A. Anuria, or the absence of urine output, occurs in later stages of shock when there is significant renal hypoperfusion. It is not an early indicator of shock.
B. Hypotension is a classic sign of shock, but it generally occurs after compensatory mechanisms have failed. It is not the earliest indicator.
C. A decreased level of consciousness occurs later in the progression of shock due to decreased cerebral perfusion. It is not the earliest sign of shock.
D. Increased respiratory rate is often the earliest indicator of shock. As the body attempts to compensate for decreased oxygen delivery and tissue perfusion, the respiratory rate increases to enhance oxygenation and eliminate excess carbon dioxide. This compensatory mechanism is typically one of the first signs that shock is developing.

Correct Answer is A

Explanation

A. The statement about keeping the temperature cold to avoid becoming overheated requires further teaching. While avoiding excessive heat is important, maintaining an overly cold environment can also trigger symptoms, such as Raynaud's phenomenon, which is common in SLE patients. Proper temperature regulation, rather than extremes, is essential.
B. Following the prescribed medication regimen and informing the healthcare provider of any side effects is crucial for managing SLE and preventing flare-ups. This demonstrates the client's understanding of the importance of medication adherence.
C. Managing stress through relaxation techniques and therapy is appropriate, as stress is known to exacerbate SLE. This statement reflects an understanding of the need to reduce stress to manage the disease effectively.
D. Wearing protective clothing when going outside is essential to prevent sun exposure, which can trigger SLE flare-ups. This indicates that the client understands the need for sun protection.

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