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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Related Questions
Correct Answer is C
Explanation
A. Incorrect. Collecting a sample of the effluent for culture and sensitivity testing may be necessary, but notifying the healthcare provider about the finding should be done first.
B. Incorrect. Stopping the exchange immediately may be necessary in some cases, but the nurse should first communicate the finding to the healthcare provider for further assessment and guidance.
C. Correct. Cloudy dialysate effluent may indicate peritonitis, an infection of the peritoneal cavity, which requires immediate attention and treatment by the healthcare provider.
D. Incorrect. Encouraging the client to perform another exchange without further assessment can potentially exacerbate any underlying issue causing the cloudy effluent.
Correct Answer is A
Explanation
A) The client's symptoms of dizziness and weakness may indicate hypotension (low blood pressure). The nurse should first check the client's blood pressure and pulse rate to assess for hypotension before implementing further interventions.
B) This statement is incorrect. Administering an antiemetic medication would not address the reported symptoms of dizziness and weakness, which may be related to changes in blood pressure.
C) This statement is incorrect. Increasing the rate of fluid removal during dialysis may exacerbate the client's symptoms of dizziness and weakness and may lead to hypotension (low blood pressure).
D) This statement is incorrect. Elevating the client's legs may help improve blood flow, but it does not address the underlying cause of the reported symptoms. The nurse should first check the client's blood pressure and pulse rate to assess for hypotension before implementing further interventions.
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