Patient Data

Exhibits here

The nurse is reviewing the history and physical.

Choose the most likely options for the information missing from the statement below by selecting from the list of options provided.

Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B"}

Choice A rationale:
Sinus tachycardia is not a cause, but a consequence of hyperkalemia.

Choice B rationale:
The client has a history of diabetes, hypertension, coronary artery disease, and end-stage renal disease, which are all risk factors for developing hyperkalemia (high levels of potassium in the blood). She also missed her scheduled dialysis session, which could have caused a buildup of potassium in her blood. Some of the signs and symptoms of hyperkalemia include fatigue, weakness, muscle cramps, tingling sensation in arms and legs, and cardiac arrhythmias such as sinus tachycardia (a fast heart rate). The other options are not consistent with the client's data or condition.

Choice C rationale:
Hypermagnesemia can also cause muscle weakness and cardiac arrhythmias, but they are less likely in this scenario since magnesium is not affected by dialysis

Choice D rationale:
Hypokalemia can also cause muscle weakness and cardiac arrhythmias, but they is less likely in this scenario since potassium is usually elevated in ESRD.

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Correct Answer is C

Explanation

Choice A rationale:
Using an incentive spirometer is not directly related to the post-TUNA discharge instructions for a client with BPH. Incentive spirometry is typically used to improve lung function and prevent respiratory complications.

Choice B rationale:
Monitoring the urinary stream for a decrease in output may be important, but it is a general instruction that may not be specific to the TUNA procedure. The primary focus after TUNA is often on monitoring for complications related to the procedure.

Choice C rationale:
Reporting when hematuria (blood in the urine) becomes pink-tinged is important. While some degree of hematuria is expected after TUNA, a change in color to pink or any other concerning changes should be reported to the healthcare provider as it could indicate complications.

Choice D rationale:
There is typically no need to restrict physical activities after a TUNA procedure. In fact, healthcare providers often encourage patients to resume normal activities gradually unless otherwise instructed due to specific complications.

A. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm. B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation. C. Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation. D. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Correct Answer is C

Explanation

Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.

Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.

Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.

Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.

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Naxlex Comprehensive Predictor Exams

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

Correct Answer is C

Explanation

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Correct Answer is C

Explanation

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