A nurse is caring for a client during his first hemodialysis treatment. The client reports a headache, nausea, and is agitated. Which of the following complications should the nurse identify these findings as manifestations of?
Disequilibrium syndrome
Septicemia
Air embolism
Peritonitis
The Correct Answer is A
Choice A reason: Disequilibrium syndrome is characterized by headache, nausea, and agitation, which can occur during or after hemodialysis, especially in the first few sessions as the body adjusts to the treatment².
Choice B reason: Septicemia would typically present with fever, chills, and hypotension, not specifically headache and agitation².
Choice C reason: Air embolism is a rare complication that would present with sudden respiratory distress, chest pain, and possibly hypotension, not just headache and agitation².
Choice D reason: Peritonitis is associated with abdominal pain and tenderness, fever, and possibly altered bowel movements, not the symptoms described².
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
Choice A reason:Profuse vomiting with a fecal odor can occur in large bowel obstructions due to the backward flow of bowel contents.
Choice B reason:Epigastric abdominal distention is a common finding in bowel obstructions due to the accumulation of gas and fluids.
Choice C reason:Intermittent abdominal cramping results from the bowel's attempt to push contents through the obstructed area.
Choice D reason:Ribbon-like stools or diarrhea may occur if there is a partial obstruction allowing some contents to pass.
Choice E reason:Metabolic acidosis can develop due to the accumulation of lactic acid from tissue hypoxia and decreased perfusion.
Choice F reason:Severe fluid and electrolyte imbalance can result from vomiting and the inability to absorb fluids and nutrients properly.
Correct Answer is A
Explanation
Choice A: Troponin Troponin levels increase within 3-12 hours from the onset of chest pain, peak at 24-48 hours, and return to baseline over 5-14 days. Troponin is a protein found in cardiac muscle fibers that regulates muscular contraction. When heart muscle is damaged, as in the case of an MI, troponin is released into the bloodstream. The elevation of troponin levels is a key indicator of myocardial infarction and can be used to diagnose and assess the extent of heart muscle damage. Troponin is the most reliable laboratory value that is expected to be elevated following a myocardial infarction, making it the correct choice in this scenario.
Choice B: Aspartate aminotransferase (AST) AST is an enzyme found in high concentrations in the liver, heart, muscles, kidneys, and brain. It is released into the bloodstream when any of these tissues are damaged. While AST can be elevated in cases of MI, it is not as specific as troponin because it is present in many other tissues besides the heart.
Choice C: Serum amylase Serum amylase is an enzyme that helps digest carbohydrates and is primarily associated with the pancreas and salivary glands. Its elevation is not specifically related to myocardial infarction but can be seen in other conditions such as pancreatitis.
Choice D: Unconjugated bilirubin Unconjugated bilirubin is a breakdown product of hemoglobin from red blood cells. Elevated levels of unconjugated bilirubin are typically associated with conditions affecting the liver or the breakdown of red blood cells, not myocardial infarction.
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