A nurse is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?
Dry mucous membranes
Trousseau's sign
Hyperactive reflexes
Irregular heart rate
The Correct Answer is D
Hyperkalemia refers to an elevated level of potassium in the blood. It can have various manifestations, and one of the critical effects of hyperkalemia is its impact on cardiac function. High levels of potassium can disrupt the normal electrical conduction in the heart, leading to arrhythmias or irregular heart rate. These arrhythmias can range from mild palpitations to more severe and life-threatening conditions like ventricular fibrillation.
Dry mucous membranes are more commonly associated with dehydration or reduced fluid intake. Hyperkalemia does not directly cause dry mucous membranes.
Trousseau's sign is a clinical manifestation of hypocalcemia, not hyperkalemia. It is characterized by carpal spasm induced by inflating a blood pressure cuff above the client's systolic blood pressure for a few minutes.
Hyperactive reflexes are commonly seen in conditions such as hyperthyroidism or certain neurologic disorders. They are not directly related to hyperkalemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Diminished pulses in the affected extremity can indicate compromised circulation, which is a serious concern. It could suggest the development of compartment syndrome, a condition characterized by increased pressure within the muscles and tissues of the leg. Compartment syndrome can lead to tissue damage and potentially jeopardize the client's limb. Therefore, it is crucial for the nurse to recognize and address this finding promptly.
One fingerbreadth of space between the cast and the skin is generally considered an appropriate amount of space to allow for swelling and adequate circulation. However, it should still be monitored for any changes or signs of compartment syndrome.
Ecchymosis on the inner left thigh may indicate bruising, which could be related to the injury or the application of the cast. While it should be documented and monitored, it does not pose an immediate threat to the client's well-being.
Client report of muscle spasms of the left leg can be a common occurrence due to muscle immobility and discomfort associated with the cast. Although it should be assessed and managed for the client's comfort, it is not as urgent as addressing compromised circulation

Correct Answer is A
Explanation
Explanation
A. Write the information at an 8 th grade reading level
Writing the information at an 8th-grade reading level ensures that it is accessible and understandable to a wide range of individuals in the community. Hypertension is a common health condition, and it is important to provide information in a clear and concise manner that can be easily comprehended by the target audience.
Explaining medical terminology using basic, one-syllable in words in (option B) is not recommendable because it may oversimplify the information and potentially undermine the importance of accuracy and precision in healthcare communication.
Using a 12-point font size in (option C) is not recommendable because it is a general guideline for readability, but it is not the most critical aspect when developing a brochure. The readability of the content itself is more important than the specific font size.
D. Presenting information from complex to simple in (option D) is not recommendable because it is not the most effective approach when developing a brochure about hypertension. It is more beneficial to present information in a simple and straightforward manner from the beginning to enhance understanding and engagement.
Therefore, the nurse should write the information at an 8th-grade reading level (option A) to ensure that it is easily accessible and comprehensible for the target audience.
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