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 B
Explanation
Choice A reason: Guilt-tripping with duty ignores caregiver burden, risking burnout. Scientifically, this lacks support for Alzheimer’s care, as emotional pressure doesn’t address practical needs, potentially worsening family stress and health outcomes contrary to holistic care principles.
Choice B reason: Offering respite care info supports the son, reducing stress with temporary relief options. Scientifically, this aligns with caregiver well-being research, as breaks improve mental health and sustain home care for Alzheimer’s, addressing his needs effectively.
Choice C reason: Suggesting other family help assumes availability, potentially straining dynamics without solutions. Scientifically, this shifts burden without support, less effective than respite, as it doesn’t guarantee aid or address the son’s immediate caregiving capacity.
Choice D reason: Long-term care is a major step, not initial support, and may feel dismissive. Scientifically, it skips intermediate options like respite, which better sustain home care for mild conditions, misaligning with gradual care escalation principles.
Correct Answer is C
Explanation
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.
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