A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?
Dry mucous membranes
Hyperactive reflexes
Trousseau's sign
Irregular heart rate
The Correct Answer is D
Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.
Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.
Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.
Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Exiting during a chemical disaster risks inhalation of toxic fumes outdoors. Scientifically, sheltering in place seals against contaminants, as evacuation exposes lungs to higher pollutant concentrations, contradicting safety protocols for chemical exposure management.
Choice B reason: Fans and AC circulate outside air, drawing in chemical toxins. Scientifically, this breaches indoor air integrity during disasters, increasing respiratory exposure to hazardous particles, opposing evidence-based sealing strategies for protection against airborne threats.
Choice C reason: Covering registers with plastic and tape seals ventilation, preventing chemical entry. Scientifically, this aligns with shelter-in-place protocols, minimizing indoor contamination by blocking airflow paths, a critical step to reduce inhalation risks during outdoor chemical disasters.
Choice D reason: Opening fireplace dampers invites chemical-laden air inside, breaching safety. Scientifically, this counters containment principles, as open vents increase exposure to toxic gases, undermining respiratory protection essential in disaster scenarios per environmental health guidelines.
Correct Answer is D
Explanation
Choice A reason: Music therapy reduces pain perception but doesn’t eliminate breakthrough pain needs. Scientifically, it’s an adjunct, not a replacement, for analgesics, as severe pain signals persist despite auditory distraction, indicating misunderstanding of its supplementary role in hospice care.
Choice B reason: Discontinuing music when unresponsive overlooks its passive benefits, like comfort, even in unconscious states. Scientifically, auditory stimuli can soothe, suggesting continued use, not cessation, misaligning with hospice goals for holistic pain management.
Choice C reason: Increasing alertness contradicts music therapy’s calming effect in hospice, aimed at relaxation, not stimulation. Scientifically, it lowers arousal to ease pain perception, not heighten awareness, showing a misgrasp of its palliative intent.
Choice D reason: Music distracts from pain by engaging the brain’s auditory cortex, reducing focus on nociceptive signals. Scientifically, this aligns with gate control theory, where non-painful stimuli mitigate pain perception, reflecting accurate understanding of its role in hospice care.
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