A nurse is monitoring a client following a hemodialysis treatment through an arteriovenous (AV) fistula. Which of the following findings should the nurse report to the provider?

Blood pressure 134/82 mm Hg

Headache, restlessness

Palpable thrill at the AV fistula access site

Heart rate 65 bpm

Answer and Explanation

The Correct Answer is B

Choice A reason: A blood pressure of 134/82 mm Hg is within the normal range and typically does not require immediate intervention. It is important to monitor blood pressure trends, but this value alone is not concerning.

Choice B reason: The correct answer is b because headache and restlessness can be signs of dialysis-related complications such as disequilibrium syndrome or fluid and electrolyte imbalances. These symptoms should be reported to the provider for further evaluation and management.

Choice C reason: A palpable thrill at the AV fistula access site indicates that the fistula is functioning properly. This is an expected finding and does not require intervention.

Choice D reason: A heart rate of 65 bpm is within the normal range for most adults and does not typically require immediate intervention unless associated with other symptoms or abnormalities.

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Correct Answer is B

Explanation

Choice A reason: Brudzinski's sign is an indicator of meningitis, where flexion of the neck causes involuntary flexion of the hips and knees. This sign is not related to hypocalcemia and is more specific to central nervous system infections.

Choice B reason: Chvostek's sign is a clinical sign of hypocalcemia. It is elicited by tapping on the facial nerve in front of the ear, which causes twitching of the facial muscles. This sign indicates neuromuscular irritability due to low calcium levels and is a key indicator for diagnosing hypocalcemia.

Choice C reason: Cullen's sign is a superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is associated with acute pancreatitis and intra-abdominal bleeding, not hypocalcemia. Therefore, it is not an appropriate sign to monitor for in clients with hypocalcemia.

Choice D reason: Kernig's sign is another indicator of meningitis. It involves pain and resistance to knee extension when the hip is flexed. Like Brudzinski's sign, it is specific to meningitis and is not related to hypocalcemia. Monitoring for this sign would not be relevant for a client with low calcium levels.

A. A dry raised rash B. Excessive salivation C. Periorbital edema D. Hardened skin

Correct Answer is D

Explanation

Choice A reason: A dry raised rash is not a typical finding in scleroderma. Scleroderma primarily affects the skin and connective tissues, leading to hardening and tightening of the skin.

Choice B reason: Excessive salivation is not associated with scleroderma. Clients with scleroderma may experience dry mouth (xerostomia) instead.

Choice C reason: Periorbital edema is not a characteristic feature of scleroderma. Scleroderma involves systemic sclerosis that affects the skin, blood vessels, and internal organs.

Choice D reason: The correct answer is d because hardened skin is a hallmark of scleroderma. This autoimmune disease causes the skin to become thickened, tight, and stiff due to excessive collagen deposition.

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A nurse is monitoring a client following a hemodialysis treatment through an arteriovenous (AV) fistula. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has scleroderma. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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