A nurse is caring for an older adult client who has a hearing aid. Which of the following actions should the nurse take when the client reports hearing a whistling sound from the hearing aid?

Explanation

Choice A Reason:

A client receives burns from a heating pad is correct. Any injury or harm caused to a client due to a medical device or equipment should be documented in an incident report for evaluation and review to prevent future incidents.

Choice B Reason:

A client's visitor becomes dizzy and faints in the client's room is incorrect. While this event might prompt the nurse to provide immediate assistance and seek medical attention for the visitor, it doesn't typically fall under the purview of an incident report unless it results from an issue within the healthcare facility.

Choice C Reason:

A client becomes disoriented and falls out of bed is correct. Falls resulting in injury or harm to the client, especially due to disorientation, should be documented to assess potential preventive measures and ensure appropriate care.

Choice D Reason:

A client reports being dissatisfied with the temperature of the meals provided is incorrect. Client dissatisfaction with meal temperature is an important concern, but it's generally addressed through communication and service improvement rather than being documented in an incident report unless it poses a risk to the client's health (e.g., if the food was excessively hot, causing harm).

Choice A Reason:

Hyperkalemia is incorrect. Vomiting and diarrhea typically lead to a loss of potassium rather than an increase. These conditions often result in depletion of electrolytes, including potassium, due to the loss of fluids.

Choice B Reason:

Hypocalcemia is correct. While prolonged or severe diarrhea could potentially lead to some electrolyte imbalances, hypocalcemia is not typically a primary finding associated with vomiting and diarrhea. Calcium levels may not be significantly affected by these symptoms compared to sodium and potassium.

Choice C Reason:

Hypermagnesemia is incorrect. Similar to calcium, magnesium levels are not usually significantly impacted by vomiting and diarrhea alone. Hypermagnesemia is more commonly associated with excessive intake of magnesium-containing medications or renal dysfunction rather than acute gastrointestinal symptoms.

In a client experiencing vomiting and diarrhea, the loss of fluids and electrolytes due to these symptoms commonly leads to:

Choice D Reason:

Hyponatremia is correct. Vomiting and diarrhea can cause a loss of sodium and water, leading to decreased sodium levels in the blood, which manifests as hyponatremia. This electrolyte imbalance is a typical finding in individuals experiencing gastrointestinal issues with fluid loss.