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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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","D","E","F"]

Explanation

Choice A rationale:
This finding suggests that the client may not be fully disclosing her symptoms or may not be aware of their significance. It should be investigated further.

Choice B rationale:
The blood pressure and heart rate are within an acceptable range, indicating that the client's blood pressure is relatively stable.

Choice C rationale:
A potassium level of 3.6 mEq/L falls within the reference range, indicating that the client's potassium level is within normal limits.

Choice D rationale:
The client's commitment to attending dialysis appointments is a positive sign, as regular dialysis is crucial for managing end-stage renal disease.

Choice E rationale:
If the client recognizes the need to resume her Lisinopril for blood pressure control, it indicates her understanding of the medication's importance in managing her hypertension.

Choice F rationale:
The client's willingness to incorporate nutrient-rich foods like dark green vegetables and potatoes into her diet is a positive sign for improving her nutritional status, which can be beneficial for her overall health. However, dietary changes should be discussed with her healthcare provider to ensure they are appropriate for her condition.

A. Compromised family coping. B. Ineffective sexual patterns. C. Impaired environmental interpretation. D. Disturbed sensory perception.

Correct Answer is D

Explanation

Choice A rationale:
Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.

Choice B rationale:
Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.

Choice C rationale:
Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.

Choice D rationale:
The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

Correct Answer is ["B","C","D","E","F"]

Explanation

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is D

Explanation

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

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