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

Potassium is an essential electrolyte that plays a crucial role in various bodily functions. However, for individuals with an electrolyte imbalance, it is often necessary to limit their potassium intake. Among the options provided, baked chicken breast is the lowest in potassium. Cantaloupe is relatively high in potassium. A cup of diced cantaloupe contains about 430 mg of potassium.

Sweet potatoes are known for their high potassium content. A medium-sized sweet potato with skin contains about 542 mg of potassium.

Orange juice also contains a moderate amount of potassium. An 8-ounce serving of orange juice typically contains around 450 mg of potassium.

Chicken breast is naturally low in potassium compared to fruits and vegetables. It contains about 260 mg of potassium per 4-ounce serving.

Therefore, among the given options, the baked chicken breast is the lowest in potassium and would be the most suitable choice for a client with an electrolyte imbalance requiring a low-potassium diet.

A. "Can you tell me about the stresses in your life?" B. "Has anyone in your family ever died by suicide? C. “Do you have a plan for harming yourself?" D. “Do you have someone to discuss your feelings with?"

Correct Answer is C

Explanation

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

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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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