Exhibits
Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:
- Fatigue
- Generalized weakness
- Muscle cramps
- Tingling sensation in her arms and legs
- Lightheadedness
She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.
Initial Vital Signs:
- Blood Pressure: 146/82 mmHg
- Heart Rate: 114 bpm
- Respiratory Rate: 18 bpm
- SpO₂: 98% on room air
- Temperature: 98.2 °F (36.8 °C) orally
Muscle cramps
Tingling sensation in her arms and legs
Lightheadedness
Fatigue
68-year-old with a history of diabetes, hypertension
Blood Pressure: 146/82 mmHg
Heart Rate: 114 bpm
Temperature: 98.2 °F
The Correct Answer is ["A","B","C"]
The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.
These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.
The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.
These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.
The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.
Correct Answer is B
Explanation
Choice A rationale:
This statement expresses the client's emotional state but does not provide information about immediate access to lethal means.
Choice B rationale:
This comment is the most crucial to document because it indicates the client's access to potentially lethal means, which is a significant risk factor for committing suicide.
Choice C rationale:
This statement provides information about a source of support in the client's life but does not indicate immediate access to lethal methods.
Choice D rationale:
This statement provides information about the frequency of panic attacks but does not indicate immediate access to lethal means.
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