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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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:
Vomiting, seizures, and loss of consciousness are more severe symptoms that are not typically associated with narcotic withdrawal but could indicate other medical issues.

Choice B rationale:
Agitation, sweating, and abdominal cramps are indicative of narcotic withdrawal. These symptoms are commonly associated with opioid withdrawal, especially when there are needle marks on the client's arms, which may suggest a history of opioid use. Opioid withdrawal symptoms can include restlessness, sweating, and gastrointestinal discomfort, such as abdominal cramps. Therefore, these findings should be documented and reported for further assessment and appropriate intervention related to narcotic withdrawal.

Choice C rationale:
Depression, fatigue, and dizziness are not specific to narcotic withdrawal and could be related to various conditions.

Choice D rationale:
Hypotension, shallow respirations, and dilated pupils may suggest opioid overdose rather than withdrawal.

A. Request backup from the staff. B. Stand in the doorway. C. Provide for personal space. D. Encourage the client to sit down.

Correct Answer is C

Explanation

Choice A rationale:
Requesting backup from the staff may be necessary if the situation escalates further, but it is not the initial action to take. Providing for personal space and attempting to de-escalate the situation should come first.

Choice B rationale:
Standing in the doorway may not be the most effective approach because it doesn't actively address the client's agitation or attempt to de-escalate the situation.

Choice C rationale:
Providing personal space is an important initial intervention when dealing with an agitated client. This approach helps maintain safety for both the nurse and the client and can reduce the perception of threat or intrusion.

Choice D rationale:
Encouraging the client to sit down may be a helpful de-escalation technique, but it should come after providing for personal space to ensure safety and reduce tension.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Correct Answer is C

Explanation

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