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: Epigastric pain suggests GI issues, not TIAs. In hypertension, TIAs affect cerebral vessels, causing neurological deficits, not abdominal symptoms like this.
Choice B reason: Seizures stem from cortical irritation, not typical TIA vascular occlusion. Hypertension-related TIAs produce transient deficits, not convulsive activity usually.
Choice C reason: Sudden monocular vision loss (amaurosis fugax) is a classic TIA sign in hypertension. It reflects temporary retinal artery occlusion, resolving quickly.
Choice D reason: Left arm pain mimics cardiac issues, not TIAs. Hypertension TIAs target brain circulation, causing focal deficits, not referred pain patterns.
Correct Answer is C
Explanation
Choice A reason: Wiping yellow crusts disrupts healing; they’re normal post-Plastibell exudate. This shows misunderstanding, as crusts should remain until the ring detaches naturally.
Choice B reason: Snug diapers risk ring displacement or irritation in Plastibell care. Loose fitting is advised, so this indicates a lack of proper technique understanding.
Choice C reason: Applying pressure with gauze controls minor bleeding, a correct response in Plastibell care. It shows understanding of managing complications until medical help is sought.
Choice D reason: Antibiotic ointment isn’t routine for Plastibell; petroleum jelly is used instead. This reflects incorrect care knowledge, potentially causing irritation or infection.
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