A nurse is collecting data from a client who is in renal failure. The nurse should identify which of the following findings is a manifestation of hyperkalemia.
Dry mucous membranes
Irregular heart rate
Hyperactive reflexes
Trousseau's sign
The Correct Answer is B
A. Incorrect. Dry mucous membranes are not typically associated with hyperkalemia.
B. Correct. Hyperkalemia can lead to cardiac dysrhythmias, including irregular heart rate.
C. Incorrect. Hyperactive reflexes are more commonly associated with hypokalemia (low potassium levels.
D. Incorrect. Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Chadwick's sign is a bluish or purplish discoloration of the vaginal and vulvar tissues due to increased vascularity that occurs during pregnancy. This is a normal finding in early pregnancy.
B. Incorrect. Chloasma refers to the appearance of dark patches on the skin, often seen on the face, and is not related to the vaginal and vulvar color changes seen in Chadwick's sign.
C. Incorrect. Hegar's sign refers to the softening of the cervix and isthmus of the uterus, not the color changes in the vaginal and vulvar tissues.
D. Incorrect. Ballottement is a physical examination technique used to assess a floating mass in the body, such as a fetus, and is not related to the color changes in the vaginal and vulvar tissues.
Correct Answer is D
No explanation
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