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 D
Explanation
Fidelity, also known as loyalty or faithfulness, refers to the nurse's commitment to keeping promises and fulfilling their responsibilities to the client. By promising to walk with the client in the outdoor courtyard each day, the nurse is demonstrating fidelity by maintaining their commitment to the client's well-being and providing the support needed to alleviate anxiety.
Autonomy refers to the client's right to make decisions about their own care and treatment. While the nurse's promise supports the client's autonomy by accommodating their preference for exercising in the courtyard, it is not the principle being demonstrated by the nurse.
Justice refers to fairness and equality in healthcare, ensuring equitable treatment and distribution of resources. While justice is an important ethical principle, it is not directly applicable in this situation.
Nonmaleficence is the principle of doing no harm and taking actions to prevent harm to the client. While the nurse's promise of walking with the client aligns with the goal of reducing anxiety, it is not specifically related to preventing harm.
Correct Answer is A
Explanation
Correct answer: A
Option A is correct.In this scenario, the social worker is likely involved in the client's care plan and needs the medical information to provide appropriate support services.Involuntary commitment: In cases of involuntary commitment, there might be a court order allowing for information sharing to ensure the client's well-being..
Option B is incorrect because sharing client information with a client's employer is generally not appropriate without the client's explicit consent. Confidentiality must be maintained, and any concerns about safety due to substance use should be discussed with the client and appropriate healthcare professionals.
Option C is incorrect.Sharing information with a nurse from another unit after a client commits suicide is generally not appropriate unless: there is a specific reason for sharing, such as identifying potential risks to other clients, the minimum amount of information necessary is shared and the sharing complies with HIPAA (Health Insurance Portability and Accountability Act) regulations.
Option D is incorrect because sharing client information with a client's partner after the client reports intimate partner abuse could potentially compromise the client's safety. It is crucial to follow specific protocols and laws related to reporting abuse while ensuring the client's confidentiality and well-being.
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