A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?
Dry mucous membranes
Hyperactive reflexes
Trousseau's sign
Irregular heart rate
The Correct Answer is D
Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.
Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.
Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.
Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Hypersomnia causes excessive sleep, not delirium’s acute confusion. It’s unrelated to the restlessness and disorientation seen in this client’s presentation.
Choice B reason: High cholesterol affects vessels, not acute brain function. It’s a chronic risk, not a trigger for delirium’s sudden cognitive shift here.
Choice C reason: UTIs in older adults often cause delirium via systemic inflammation and toxins. This matches the client’s disorientation and restlessness as a risk.
Choice D reason: Amyloid plaque links to Alzheimer’s, a chronic condition. Delirium is acute; plaque doesn’t explain the sudden onset in this scenario.
Correct Answer is C
Explanation
Choice A reason: A chaplain offers spiritual support, but it’s not the nurse’s primary role. Autonomy in end-stage kidney disease takes precedence over initiating such visits.
Choice B reason: Alternatives don’t apply post-decision in end-stage disease; dialysis cessation reflects prognosis acceptance. Discussing them now dismisses the client’s informed choice.
Choice C reason: Supporting the decision respects autonomy in end-stage kidney disease. It aligns with palliative care, honoring the client’s right to refuse treatment.
Choice D reason: Suggesting family discussion undermines autonomy, adding pressure. In terminal illness, the client’s choice to stop dialysis should be respected directly.
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