A client on hemodialysis presents with a severe headache, confusion, and seizures. What action should the nurse take first?
Administer an antiepileptic medication.
Assess the client's blood glucose levels.
Document the findings and monitor the client.
Check the client's pre-dialysis weight.
The Correct Answer is B
A. Incorrect. While administering an antiepileptic medication may be necessary if the client is experiencing seizures, it is essential to identify the underlying cause first.
B. Correct. The client's severe headache, confusion, and seizures may be indicative of dialysis disequilibrium syndrome, which is a complication of rapid solute removal during hemodialysis. Hypoglycemia can also present with similar symptoms, so assessing blood glucose levels is crucial to differentiate between the two conditions.
C. Incorrect. Documenting the findings and monitoring the client's condition are important, but addressing the acute symptoms and potential cause should be the priority.
D. Incorrect. Checking the client's pre-dialysis weight is not the priority when the client is experiencing severe neurological symptoms. Immediate assessment and intervention are needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This statement is accurate. Hypertonic dialysate has a higher concentration of glucose, which results in increased fluid removal from the client's peritoneal cavity. This type of dialysate is often used for more effective ultrafiltration.
B) This statement is incorrect. Infusing hypertonic dialysate does not result in decreased urine output. Peritoneal dialysis is a process of exchanging fluids and waste products through the peritoneal membrane, but it does not directly affect urine production.
C) This statement is incorrect. Infusing hypertonic dialysate would not lead to hydration overload, as it causes fluid to be removed from the body.
D) This statement is incorrect. Hypertonic dialysate would not cause hypotension. In fact, it may lead to a decrease in blood pressure due to fluid removal, but it would not be considered a primary cause of hypotension.
Correct Answer is C
Explanation
A. Incorrect. Administering a calcium channel blocker is not the first-line intervention for muscle cramps during dialysis.
B. Incorrect. Slowing down the blood flow rate during dialysis may be necessary in some cases, but it is not the first action to address muscle cramps.
C. Correct. Muscle cramps during dialysis can be caused by electrolyte imbalances, such as low potassium levels. Offering the client a sports drink with electrolytes can help alleviate the cramps.
D. Incorrect. Applying a heating pad to the affected muscles is not recommended during dialysis, as it may cause burns or worsen the cramps.
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