A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?
Dry mucous membranes
Trousseau's sign
Hyperactive reflexes
Irregular heart rate
The Correct Answer is D
Hyperkalemia refers to an elevated level of potassium in the blood. It can have various manifestations, and one of the critical effects of hyperkalemia is its impact on cardiac function. High levels of potassium can disrupt the normal electrical conduction in the heart, leading to arrhythmias or irregular heart rate. These arrhythmias can range from mild palpitations to more severe and life-threatening conditions like ventricular fibrillation.
Dry mucous membranes are more commonly associated with dehydration or reduced fluid intake. Hyperkalemia does not directly cause dry mucous membranes.
Trousseau's sign is a clinical manifestation of hypocalcemia, not hyperkalemia. It is characterized by carpal spasm induced by inflating a blood pressure cuff above the client's systolic blood pressure for a few minutes.
Hyperactive reflexes are commonly seen in conditions such as hyperthyroidism or certain neurologic disorders. They are not directly related to hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This response allows the nurse to express genuine interest in the client's perspective and opens up a dialogue to understand the client's concerns or reasons for refusing to learn how to self-administer insulin. It provides an opportunity for the client to express their fears, doubts, or any barriers they may have. By actively listening to the client, the nurse can better address their concerns and provide appropriate education and support tailored to their individual needs.
The other options may come across as confrontational, judgmental, or unhelpful in establishing a therapeutic relationship with the client. It is important for the nurse to approach the situation with empathy, respect, and a non-judgmental attitude to foster effective communication and promote the client's engagement in their own care.
Correct Answer is D
Explanation
A.The prescription specifies “four times per day,” which is clear.
B.The medication specified is erythromycin, which is clear
C.The dosage of 500 mg is clearly specified.
D.The route of administration eg. oral, topical is not specified and needs to be clarified to ensure proper administration.
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