Patient Data
The nurse is reviewing the history and physical.
Choose the most likely options for the information missing from the statement below by selecting from the list of options provided.
Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a .
The Correct Answer is {"dropdown-group-1":"B"}
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
While it's important for the client to be aware of the signs and symptoms of their illness, medication monitoring is a more immediate concern.
Choice B rationale:
Participating in therapy can be beneficial, but it's not the most critical information to provide in this context.
Choice C rationale:
Living away from home is possible for many individuals with bipolar disorder, but medication management is a higher priority.
Choice D rationale:
Routine monitoring of serum lithium levels is crucial to ensure therapeutic levels and prevent lithium toxicity in individuals taking lithium carbonate for bipolar disorder.
Correct Answer is B
Explanation
A. Assisting the client with relaxation techniques within the group may be ineffective for severe anxiety because the client may be too overwhelmed by the environment to participate or focus.
B. Escorting the client from the group to a quieter environment is the most effective intervention for severe anxiety. Reducing external stimuli allows the client to regain composure and prevents escalation of physiological and psychological stress responses.
C. Providing education about coping strategies is appropriate for mild or moderate anxiety, but during severe anxiety the client is unlikely to process or retain information effectively.
D. Asking the client to describe or identify the source of feelings can increase anxiety and is not therapeutic during a severe anxiety episode. Exploration of triggers is more appropriate once the client is calmer.
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