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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Explanation:

Avoid pregnancy for at least 28 days after receiving the vaccine: This is a crucial instruction for women of childbearing age. The MMR vaccine is a live attenuated vaccine, and women should avoid becoming pregnant for at least 28 days after receiving it to reduce the theoretical risk to the developing fetus. Pregnant women should not receive the MMR vaccine, and women who receive the vaccine should avoid getting pregnant for at least 28 days afterward.

Incorrect:

A- Avoid breastfeeding for 3 days after receiving the vaccine: This statement is not accurate. Breastfeeding is not contraindicated after receiving the MMR vaccine. In fact, breastfeeding is safe and can be continued as usual.

B- Your partner should also receive the MMR vaccine: While it is essential for individuals to be vaccinated against measles, mumps, and rubella for their own protection and to contribute to herd immunity, it is not a specific instruction given to the postpartum client.

C- If you are allergic to gluten, you should not receive this vaccine: The MMR vaccine does not contain gluten, and a gluten allergy is not a contraindication for receiving the vaccine.

A. "I can have two glasses of wine with dinner." B. "I will set my blood pressure goal at 130 over 84. C. "I should decrease my salt intake to 2 grams per day." D. "I should exercise for 15 minutes two times per week."

Correct Answer is C

Explanation

"I should decrease my salt intake to 2 grams per day." - This statement is correct. Decreasing salt intake is an important dietary modification for individuals with hypertension. The general recommendation is to limit sodium intake to 2 grams per day or less. Reducing salt intake can help lower blood pressure levels.

"I can have two glasses of wine with dinner." - This statement is not accurate. While moderate alcohol consumption may have some health benefits, it is generally recommended to limit alcohol intake, especially for individuals with hypertension. The specific recommendation for alcohol consumption may vary depending on individual factors and should be discussed with a healthcare provider.

"I should exercise for 15 minutes two times per week." - This statement is not accurate. While any amount of physical activity is beneficial, the current recommendations for adults include at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, along with muscle-strengthening activities on two or more days. The client should aim for a higher frequency and duration of exercise to achieve optimal health benefits.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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