A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?

Give a dose of alendronate.

Administer furosemide.

Apply a cardiac monitor.

Monitor for Chvostek's sign.

Answer and Explanation

The Correct Answer is C

A. Give a dose of alendronate is incorrect. Alendronate is a medication used to treat osteoporosis, and it does not address low potassium levels. In this case, the focus should be on correcting the potassium imbalance.

B. Administer furosemide is incorrect. Furosemide is a diuretic that can cause further loss of potassium. In a client with low potassium levels (hypokalemia., administering furosemide could worsen the condition and lead to life-threatening complications.

C. Apply a cardiac monitor is correct. Hypokalemia (potassium level of 2.9 mEq/L) can cause significant cardiac arrhythmias, including ventricular tachycardia or fibrillation. Applying a cardiac monitor is essential for monitoring the client’s heart rhythm and detecting any abnormalities related to the low potassium level.

D. Monitor for Chvostek's sign is incorrect. Chvostek's sign is indicative of hypocalcemia, not hypokalemia. While both hypocalcemia and hypokalemia can cause neuromuscular excitability, monitoring for Chvostek’s sign is not a priority in the management of hypokalemia.

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Correct Answer is A

Explanation

A. "It is your choice to share personal information during group therapy" is correct. The ethical principle of autonomy emphasizes respecting a client's right to make decisions about their own care, including the right to share or withhold personal information. Allowing the client to choose what to share supports their independence and decision-making ability.

B. "I will be truthful when answering questions about your treatment" promotes veracity, not autonomy. While truthfulness is important in nursing, it does not directly pertain to the principle of client autonomy.

C. "The nursing staff here will provide you with nonjudgmental care" promotes beneficence and respect for the client's dignity, but it does not directly address the principle of autonomy, which focuses on the client’s ability to make choices.

D. "I will only discuss your medical information with the health care team" supports confidentiality and privacy, not autonomy. Autonomy involves respecting a client’s decision-making, not just protecting their information.

A. "This must be very frightening for you. Let's talk more about it." B. "What makes you think the staff is following you?" C. “Why do you feel the staff is the FBI?" D. "The psychiatric staff is not FBI. They are here to help you."

Correct Answer is A

Explanation

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.

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A nurse is contributing to the plan of care for a client who has a potassium level of 2.9 mEq/L. Which of the following actions should the nurse plan?

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