The nurse is caring for a patient who is experiencing disequilibrium syndrome during hemodialysis. Which of the following interventions will the nurse implement for this patient? (Select All That Apply)

Administer a rapid infusion of fluids.

Increase the dialysis flow rate.

Decrease the rate of dialysis.

Apply ice packs to the patient's head.

Monitor neurological status closely.

Answer and Explanation

Correct Answer : C

Choice A reason: Administering a rapid infusion of fluids is not appropriate for disequilibrium syndrome. This syndrome results from rapid changes in fluid and electrolyte balance during dialysis, and rapid fluid infusion could worsen the condition.

Choice B reason: Increasing the dialysis flow rate is not appropriate. Decreasing the rate of dialysis can help reduce the symptoms of disequilibrium syndrome by allowing the body to adjust more gradually.

Choice C reason: Decreasing the rate of dialysis helps to minimize the rapid shifts in fluid and electrolytes, which can exacerbate disequilibrium syndrome.

Choice D reason: Applying ice packs to the patient's head is not a standard intervention for disequilibrium syndrome. The focus should be on managing the rate of dialysis and monitoring the patient's neurological status.

Choice E reason: Monitoring neurological status closely is important because disequilibrium syndrome can cause symptoms such as headache, nausea, confusion, and seizures. Close monitoring allows for prompt intervention if symptoms worsen.

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Correct Answer is B

Explanation

Choice A reason: Scattered petechiae on bilateral lower extremities are a common finding in patients with thrombocytopenia, indicating low platelet count and increased risk of bleeding. While this finding is concerning, it is not as immediate a threat as significant bleeding or bruising.

Choice B reason: Ecchymosis around the intravenous site suggests significant bleeding and bruising, which can be more urgent and requires immediate reporting. A platelet count of 10,000/mm³ is critically low, increasing the risk of spontaneous bleeding and haemorrhage. Immediate intervention is necessary to prevent further complications.

A. "I will adhere to my medication regimen even when I am not experiencing symptoms." B. "I will maintain regular physical activity and exercise with planned rest periods." C. "I will soak in a hot bath every night to help with muscle weakness and fatigue." D. "I will identify strategies to control anxiety and physical stress to prevent exacerbations."

Correct Answer is C

Explanation

Choice A reason: Adhering to the medication regimen even when not experiencing symptoms is crucial for managing multiple sclerosis (MS). MS is a chronic condition that requires consistent treatment to prevent relapses and slow disease progression. This statement indicates proper understanding of medication adherence.

Choice B reason: Maintaining regular physical activity and exercise with planned rest periods is important for managing MS. Physical activity helps maintain muscle strength, flexibility, and overall health, while planned rest periods prevent overexertion and fatigue. This statement indicates proper understanding of balancing activity and rest.

Choice C reason: Soaking in a hot bath every night to help with muscle weakness and fatigue requires further teaching. Heat can exacerbate MS symptoms, leading to increased fatigue and muscle weakness. Patients with MS are often advised to avoid hot baths and instead use cool or lukewarm water for comfort. This statement indicates a misunderstanding of how to manage symptoms effectively.

Choice D reason: Identifying strategies to control anxiety and physical stress to prevent exacerbations is important for managing MS. Stress can trigger MS relapses and worsen symptoms. Developing stress management techniques helps reduce the risk of exacerbations. This statement indicates proper understanding of the importance of stress management.

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The nurse is caring for a patient who is experiencing disequilibrium syndrome during hemodialysis. Which of the following interventions will the nurse implement for this patient? (Select All That Apply)

Nursing Test Bank

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