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

Choice A rationale:
This is included because the client has a history of cardiovascular issues (hypertension, coronary artery disease), and the symptoms presented (fatigue, muscle cramps, tingling sensation, lightheadedness) could be related to cardiac concerns. Monitoring cardiac status helps assess for any cardiac-related issues.

Choice B rationale:
This is essential because the client's recent illness and missed dialysis sessions may have contributed to her symptoms. Ensuring the client understands the importance of compliance with hemodialysis is crucial for her overall well-being.

Choice C rationale:
Monitoring vital signs, including blood pressure, heart rate, and respiratory rate, is a fundamental aspect of assessing the client's current condition and response to treatment.

Choice D rationale:
A comprehensive head-to-toe assessment helps identify any physical signs or symptoms that may be contributing to the client's complaints and guides further evaluation and interventions.

Choice E rationale:
Given the client's history of cardiovascular disease and the complaints of chest discomfort, monitoring the heart rhythm is essential to assess for any arrhythmias or irregularities.

Choice F rationale:
Monitoring fluid intake and output is crucial, especially in clients with end-stage renal disease, as imbalances in fluid and electrolytes can exacerbate symptoms and lead to complications.

Choice G rationale:
The client's complaints of muscle cramps and tingling sensations in the arms and legs indicate potential neuromuscular involvement. Monitoring neuromuscular status helps assess these symptoms.

Choice H rationale:
There is no indication in the provided information that an immediate transfer to a telemetry unit is necessary. The client's vital signs, including heart rate and oxygen saturation, are stable at the moment. Further assessment and interventions can be carried out on the current unit before considering a transfer.

Choice I rationale:
Given the client's history of end-stage renal disease and the symptoms presented, educating her to avoid a high-potassium diet is important. High potassium levels can lead to symptoms like muscle cramps and tingling sensations, which the client is experiencing.

Choice A rationale:
Postponing the interview until the next day may not be necessary and could delay necessary assessment and care.
Choice B rationale:
Documenting the client's paranoid behavior is important but should be done after the nurse attempts to engage with the client.
Choice C rationale:
Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish some rapport. It respects the client's need for space while initiating communication.
Choice D rationale:
Asking another nurse to talk with the client may be an option later if the client remains uncooperative, but the nurse should first attempt to engage with the client directly.