A patient with primary hyperparathyroidism has a serum calcium level of 14 mg/dl (3.5 mmol/L), phosphorus of 1.7 mg/dl (55 mmol/L), serum creatinine of 2.2 mg/dl (194 mmol/L). and high urine calcium. While the patient awaits surgery, the nurse should:
institute seizure precautions such as padded side rails.
assist the patient to perform range-of-motion exercises QID.
encourage the patient to drink 4000 ml of fluid daily.
monitor the patient for positive Chvostek’s or Trousseaus sign.
The Correct Answer is C
The patient with primary hyperparathyroidism has high levels of calcium in the blood (hypercalcemia) which can lead to symptoms such as kidney stones, bone pain, and weakness. High urine calcium levels may also be present due to the increased calcium in the blood.
One important intervention for managing hypercalcemia is to encourage fluid intake to promote increased urine output and prevent the formation of kidney stones. Therefore, the nurse should encourage the patient to drink at least 4000 ml of fluids per day.
Seizure precautions (a), range-of-motion exercises (b), and monitoring for positive Chvostek’s or Trousseaus sign (d) are not directly related to managing hypercalcemia and are not necessary in this case.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Based on the given documentation, the nurse suspects that the client has respiratory alkalosis. The client's ABG results show a pH of 7.52, which indicates alkalosis and the PaO2 level is slightly low, suggesting respiratory involvement. Rapid breathing (RR44) and wheezing also support the possibility of respiratory alkalosis.
Correct Answer is B
Explanation
The statement "I had the stomach flu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineffective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.
Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.
The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.
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