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The nurse is caring for a client with end-stage renal disease (ESRD) who is anuric and receives hemodialysis three times a week. During a routine assessment, the patient expresses frustration about strict fluid restrictions and states, “I don’t even make urine anymore, so why does it matter how much I drink?” Which of the following is the most appropriate response by the nurse?

Because your kidneys no longer produce urine, fluid can build up quickly and lead to complications like high blood pressure or difficulty breathing

You should actually drink more fluids to stay hydrated since you’re not urinating

As long as you’re attending all your dialysis sessions, your fluid intake doesn’t need to be restricted

It’s not the fluids that are harmful, it’s the foods that are high in potassium and phosphorus

Answer and Explanation

The Correct Answer is A

Choice A reason: In ESRD, anuria means no urine output, so excess fluid accumulates in the body, increasing intravascular volume. This can cause hypertension, pulmonary edema, and respiratory distress. Educating the client about these risks emphasizes the importance of fluid restrictions to prevent life-threatening complications between dialysis sessions, addressing their frustration accurately.

Choice B reason: Advising increased fluid intake is incorrect for anuric ESRD patients, as their kidneys cannot excrete fluid. This would exacerbate fluid overload, leading to hypertension, heart failure, or pulmonary edema. Hydration is managed through dialysis, not increased oral intake, which could overwhelm the body’s limited fluid-handling capacity.

Choice C reason: Stating that fluid intake is unrestricted with dialysis is incorrect. Even with regular dialysis, excessive fluid intake between sessions can lead to overload, causing hypertension or pulmonary edema. Dialysis removes a limited amount of fluid per session, requiring strict restrictions to maintain safe fluid balance and prevent complications.

Choice D reason: While potassium and phosphorus restrictions are critical in ESRD to prevent hyperkalemia and hyperphosphatemia, the client’s question focuses on fluid restrictions. This response does not address fluid overload risks like hypertension or pulmonary edema, which are direct consequences of excessive fluid intake in anuric patients, making it irrelevant to the query.

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Correct Answer is C

Explanation

Choice A reason: Restraining and forcibly administering medication violates patient autonomy and ethical principles, potentially escalating agitation in psychosis. It risks physical harm and legal issues, as forced medication requires specific legal orders (e.g., involuntary commitment). Non-invasive approaches like negotiation or assessing refusal reasons are safer and more ethical.

Choice B reason: Stating that refusal prevents improvement is coercive and undermines autonomy. It fails to explore reasons for refusal, such as side effect concerns or psychosis-related mistrust, which are common in severe psychosis. This approach may damage trust and hinder therapeutic alliance, making it inappropriate as an initial action.

Choice C reason: Accepting the client’s refusal respects autonomy while prioritizing safety, critical in psychosis where agitation is common. This allows exploration of refusal reasons (e.g., paranoia) and alternative interventions, maintaining a therapeutic environment. Monitoring ensures no immediate harm, making this the most ethical and safe initial response.

Choice D reason: Obtaining a discharge order for nonadherence is premature and inappropriate, as refusal does not warrant immediate discharge. Psychosis requires ongoing assessment and management, and discharge could exacerbate symptoms or risk harm, making this action contrary to the goal of stabilizing the client’s mental health.

A. Apologize for asking such a personal and intrusive question B. Encourage the client to make a list of their concerns and offer to discuss it with them on how to cope with homelessness C. Divert the subject to something the client will readily discuss D. Sit quietly allowing the client time to process before responding

Correct Answer is D

Explanation

Choice A reason: Apologizing for the question may imply it was inappropriate, undermining the therapeutic intent to explore emotions. Homelessness is a valid topic in mental health care, and apologizing could discourage further discussion, disrupting trust and the client’s ability to process and express difficult emotions.

Choice B reason: Encouraging a list of concerns shifts focus to problem-solving prematurely, potentially overwhelming the client who is processing emotions. This action disregards the client’s need for reflection, which is critical in therapeutic communication to facilitate emotional expression and address underlying psychological distress effectively.

Choice C reason: Diverting the subject avoids the client’s emotional response, missing a therapeutic opportunity to explore feelings about homelessness. This can signal discomfort with the topic, reducing trust and hindering the client’s ability to process trauma, which is essential for mental health recovery and coping.

Choice D reason: Sitting quietly allows the client time to process complex emotions about homelessness, fostering a safe therapeutic environment. Silence supports reflection, enabling the client to articulate feelings at their pace, which enhances trust and facilitates deeper emotional exploration, making it the most therapeutic response in this context.

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes haloperidol 10 mg for a client with severe psychosis, but the client refuses the medication. Which initial nursing action is appropriate?

Correct Answer is C

Explanation

The nurse asks the client, “What was it like for you when you first realized you had no place to go?” The client looks down and pauses for quite some time. Which action by the nurse is most therapeutic?

Correct Answer is D

Explanation

The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

A nurse is caring for a client who is in the diuresis phase of acute kidney injury. The nurse should closely monitor the client for what complication during this phase?

An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

A client diagnosed with end-stage kidney injury receives continuous ambulatory peritoneal dialysis (CAPD). The nurse observes that the dialysate drainage fluid is cloudy. What is the priority intervention?

A nurse working on a psychiatric unit receives a telephone call from a client’s employer requesting a copy of the client’s psychological evaluation results. Based on the nurse’s knowledge of breach of confidentiality, which response would be appropriate?

A client with a history of chronic renal failure receives hemodialysis treatment three times per week through an arteriovenous (AV) fistula in the left arm. Which priority intervention should the nurse include in the care plan?

A nurse is planning the discharge of a client with a mental health disorder. Which factor does the nurse identify as the best chance for the client to remain in the community without readmission?