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Exhibits

Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse.

The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with:

Fatigue

Generalized weakness

Muscle cramps

Tingling sensation in her arms and legs

Lightheadedness

She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.

Initial Vital Signs:

Blood Pressure: 146/82 mmHg

Heart Rate: 114 bpm

Respiratory Rate: 18 bpm

SpO₂: 98% on room air

Temperature: 98.2 °F (36.8 °C) orally

Muscle cramps

Tingling sensation in her arms and legs

Lightheadedness

Fatigue

68-year-old with a history of diabetes, hypertension

Blood Pressure: 146/82 mmHg

Heart Rate: 114 bpm

Temperature: 98.2 °F

Answer and Explanation

The Correct Answer is ["A","B","C"]

The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness.

These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma.

The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.

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Correct Answer is {"dropdown-group-1":"B"}

Explanation

Choice A rationale:
Sinus tachycardia is not a cause, but a consequence of hyperkalemia.

Choice B rationale:
The client has a history of diabetes, hypertension, coronary artery disease, and end-stage renal disease, which are all risk factors for developing hyperkalemia (high levels of potassium in the blood). She also missed her scheduled dialysis session, which could have caused a buildup of potassium in her blood. Some of the signs and symptoms of hyperkalemia include fatigue, weakness, muscle cramps, tingling sensation in arms and legs, and cardiac arrhythmias such as sinus tachycardia (a fast heart rate). The other options are not consistent with the client's data or condition.

Choice C rationale:
Hypermagnesemia can also cause muscle weakness and cardiac arrhythmias, but they are less likely in this scenario since magnesium is not affected by dialysis

Choice D rationale:
Hypokalemia can also cause muscle weakness and cardiac arrhythmias, but they is less likely in this scenario since potassium is usually elevated in ESRD.

A. An adult with schizophrenia who often refuses to take prescribed antipsychotic medications. B. A hyperactive 4-year-old who has recently been tested for autism. C. An older adult resident of a long-term care facility who sometimes takes other residents' belongings. D. An adolescent who is depressed over not being accepted by peers.

Correct Answer is D

Explanation

Choice A rationale:
An adult with schizophrenia who often refuses to take prescribed antipsychotic medications may require a different approach, such as medication education or supportive therapy.

Choice B rationale:
A hyperactive 4-year-old who has recently been tested for autism may benefit from play therapy or other age-appropriate interventions rather than role-playing.

Choice C rationale:
An older adult resident of a long-term care facility who sometimes takes other residents' belongings may require interventions focused on behavior management and addressing the underlying causes of this behavior.

Choice D rationale:
Role-playing can be an effective therapeutic intervention for individuals who need to practice social skills, communication, and problem-solving in a safe and controlled environment. In this case, the adolescent who is depressed over not being accepted by peers may benefit from role-playing to develop and practice social skills, assertiveness, and coping strategies for peer interactions.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B"}

Explanation

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?

Correct Answer is D

Explanation

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