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?

Choice A reason: Standing in front risks escalation and injury; de-escalation needs space. Safety protocol prioritizes staff positioning away from a combative client’s reach.

Choice B reason: Standing orders for restraints vary; immediate application skips assessment. Ensuring staff support first allows safer, assessed intervention per guidelines.

Choice C reason: Adequate staff ensures safe de-escalation or restraint if needed. It’s the priority, reducing risk to all in a combative situation effectively.

Choice D reason: PRN restraint orders follow de-escalation attempts; staff availability precedes this. Immediate safety via numbers is critical before seeking prescriptions here.

Choice A reason: Family history informs genetic risks, not current mobility needs for therapy. Scientifically, it’s less relevant than functional data, as physical therapy focuses on present deficits, not hereditary patterns, making this secondary for referral purposes.

Choice B reason: Prior medications provide context but don’t detail current physical status for therapy goals. Scientifically, recent assessments outweigh past drug use, as therapists need functional baselines, not historical pharmacology, for effective planning.

Choice C reason: Physical assessment findings (e.g., strength, range of motion) directly inform therapy needs, setting baselines for intervention. Scientifically, this data drives rehabilitation plans, aligning with evidence-based practice to target specific deficits for mobility recovery.

Choice D reason: Insurance claims are administrative, not clinical, data. They don’t guide therapy goals or interventions. Scientifically, financial details are irrelevant to physical assessment, making this inappropriate for a referral focused on functional restoration.