The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.

Preoccupation.

Reexperience.

Somatization.

Disorganization.

Answer and Explanation

The Correct Answer is C

Choice A rationale:
Preoccupation typically involves excessive thoughts or worries about a particular topic and may not directly manifest as physical symptoms like numbness and tingling.

Choice B rationale:
Reexperience often refers to the reliving of traumatic events through flashbacks or intrusive memories and is more closely associated with conditions like post-traumatic stress disorder (PTSD).

Choice C rationale:
Somatization refers to the expression of psychological distress through physical symptoms. In this case, the client's numbness and tingling on the right side of the body may be somatic symptoms related to the psychological distress and grief experienced after the spouse's death.

Choice D rationale:
Disorganization is not typically associated with physical symptoms like numbness and tingling. It may relate to cognitive or emotional difficulties but not to these specific physical sensations.

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

Explanation

Choice A rationale:
This is not a priority action for the nurse at this time. The nurse should first implement the ordered treatments for hyperkalemia and stabilize the client's condition before calling and giving a report to the receiving unit.

Choice B rationale:
Loop diuretics are medications that increase urine output and can lower potassium levels in mild cases of hyperkalemia. However, they are contraindicated in patients with ERSD who have oliguria or anuria (reduced or absent urine production). Loop diuretics can worsen renal function and fluid overload in these patients.

Choice C rationale:
Scheduling the client for hemodialysis is crucial, especially if the client has missed a scheduled dialysis session. Hemodialysis can help manage electrolyte imbalances and fluid overload.

Choice D rationale:
Checking the blood glucose level is important, especially in a client with a history of diabetes. Maintaining glycemic control is essential for overall health.

Choice E rationale:
Drawing a repeat potassium level is necessary to monitor the client's electrolyte status, especially given the ECG changes.

Choice F rationale:
Holding Lisinopril, an ACE inhibitor, is appropriate in this context, considering the client's elevated blood pressure and potential renal issues. It should be done under the guidance of the healthcare provider.

Choice G rationale:
Administering insulin, dextrose, and calcium gluconate can help manage hyperkalemia, which may be indicated by the ECG changes. Repeating the 12-lead EKG is important to assess the response to treatment and any changes in cardiac rhythm.

A. Muscle cramps B. Tingling sensation in her arms and legs C. Lightheadedness D. Fatigue E. 68-year-old with a history of diabetes, hypertension F. Blood Pressure: 146/82 mmHg G. Heart Rate: 114 bpm H. Temperature: 98.2 °F

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.

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The nurse is assessing a client whose spouse died of a stroke two weeks ago and who reports having numbness and tingling on the right side of the body. The nurse should consider the client's symptoms may likely be due to which condition.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

Correct Answer is ["A","B","C"]

Explanation

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