A client with an implanted cardioverter defibrillator (ICD) reports to the home health nurse feeling dizzy when the device discharges. Which intervention is most important for the nurse to implement?

Provide the client with written guidelines about avoiding electromagnetic fields.

Use a hand held magnet to reprogram the sensitivity of the ICD.

Advise the client to lie down immediately when dizziness occurs.

Instruct the client to obtain a 24 hour portable electrocardiogram (ECG) monitor.

Answer and Explanation

The Correct Answer is C

Rationale:

A. Provide the client with written guidelines about avoiding electromagnetic fields: Education about electromagnetic interference is important for long-term device safety, but it does not address the client’s immediate symptom of dizziness associated with ICD discharge. The priority is preventing injury during an acute episode.

B. Use a hand held magnet to reprogram the sensitivity of the ICD: Reprogramming or altering ICD function is not within the nurse’s scope in the home setting and can suppress lifesaving therapy. This action should only be performed by qualified providers in a controlled environment.

C. Advise the client to lie down immediately when dizziness occurs: Dizziness after ICD discharge may result from transient decreased cerebral perfusion or arrhythmia. Lying down reduces the risk of falls and injury and supports cerebral blood flow during the episode.

D. Instruct the client to obtain a 24 hour portable electrocardiogram (ECG) monitor: Ambulatory monitoring may be useful for evaluating arrhythmias, but it does not address immediate safety concerns when dizziness occurs following ICD discharge.

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Correct Answer is C

Explanation

Rationale:
A. Hypotension: Acute pancreatitis can cause third-spacing and fluid shifts leading to hypotension, but this finding reflects intravascular volume depletion rather than a direct electrolyte disturbance. It is more closely related to hypovolemia and systemic inflammatory response.

B. Paralytic ileus and abdominal distention: Ileus commonly occurs in acute pancreatitis due to inflammation and peritoneal irritation. While electrolyte abnormalities can worsen ileus, this finding primarily reflects gastrointestinal motility impairment rather than a specific electrolyte imbalance.

C. Muscle twitching and digit numbness: Acute pancreatitis frequently causes hypocalcemia due to fat necrosis binding calcium. Neuromuscular irritability such as muscle twitching, perioral tingling, and numbness of digits are classic signs of low serum calcium. This finding directly indicates an electrolyte imbalance.

D. Hyperglycemia: Hyperglycemia results from impaired insulin secretion due to pancreatic inflammation. It reflects endocrine dysfunction rather than an electrolyte imbalance. Although common in pancreatitis, it does not indicate disturbed electrolyte levels.

A. Report signs of increasing irritability. B. Administer a PRN antiemetic. C. Monitor serum sodium levels. D. Assess for peripheral edema daily.

Correct Answer is C

Explanation

Rationale:
A. Report signs of increasing irritability: Changes in mental status, such as irritability, can indicate worsening hyponatremia. While important to monitor, this is a symptom rather than a direct measure of the client’s condition.

B. Administer a PRN antiemetic: Anti-nausea medication may relieve symptoms but does not address the underlying electrolyte imbalance or prevent complications of SIADH. It is supportive care, not a priority intervention.

C. Monitor serum sodium levels: Hyponatremia is the hallmark of SIADH and can lead to seizures, coma, or death if severe. Frequent monitoring of serum sodium is critical to guide fluid restriction, hypertonic saline administration, and other interventions, making it the most important nursing action.

D. Assess for peripheral edema daily: SIADH typically causes water retention without significant peripheral edema because fluid accumulates intracellularly rather than in the interstitial space. Monitoring edema is less critical than tracking serum sodium.

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A client with an implanted cardioverter defibrillator (ICD) reports to the home health nurse feeling dizzy when the device discharges. Which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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