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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) This statement is incorrect. Hypercalcemia (elevated calcium levels) can be a concern in ESRD, but it is not the primary indication for initiating dialysis in this scenario. Pruritus is more commonly associated with uremia and high levels of other waste products.
B) This statement is incorrect. Hypervolemia (fluid overload) can be a concern in ESRD, but it is not the primary indication described in the scenario. The persistent pruritus is more likely related to uremia and the accumulation of toxins.
C) This statement is incorrect. Hyperkalemia (elevated potassium levels) is not the primary indication described in the scenario. While hyperkalemia may occur in ESRD, the primary concern leading to the need for dialysis in this case is the uremia and its associated symptoms.
D) Uremia, which is the accumulation of urea and other waste products in the blood, can lead to various complications, including pruritus. Dialysis helps remove these waste products from the bloodstream and may alleviate the itching associated with uremia.
Correct Answer is B
Explanation
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.
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