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 B
Explanation
Choice A rationale:
Vomiting, seizures, and loss of consciousness are more severe symptoms that are not typically associated with narcotic withdrawal but could indicate other medical issues.
Choice B rationale:
Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal. These symptoms are commonly associated with opioid withdrawal, especially when there are needle marks on the client's arms, which may suggest a history of opioid use. Opioid withdrawal symptoms can include restlessness, sweating, and gastrointestinal discomfort, such as abdominal cramps. Therefore, these findings should be documented and reported for further assessment and appropriate intervention related to narcotic withdrawal.
Choice C rationale:
Depression, fatigue, and dizziness are not specific to narcotic withdrawal and could be related to various conditions.
Choice D rationale:
Hypotension, shallow respirations, and dilated pupils may suggest opioid overdose rather than withdrawal.
Correct Answer is A
Explanation
Choice A rationale:
Encouraging the mother to write her thoughts and feelings in a journal is a constructive and therapeutic response. It provides an outlet for the mother to express her emotions and can be a helpful tool for coping with the challenges she is facing.
Choice B rationale:
Determining if the mother has other children who do not have developmental disabilities may be relevant to understanding her support system and family dynamics, but it does not directly address her current emotional distress.
Choice C rationale:
Reassuring the mother that her child will achieve some growth and development milestones may not be appropriate in this situation, as the child's disabilities are described as profound, and it is uncertain what milestones the child will reach. Providing false hope may not be helpful and could be misleading.
Choice D rationale:
Asking the mother if she has ever thought about harming herself or her child is an important inquiry related to her emotional state and the potential risk of harm. However, it should follow the initial response of encouraging her to express her thoughts and feelings in a journal.
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