Exhibits

For each client statement, select the statement(s) below that require follow-up teaching by the nurse.

"This diagnosis means that I am crazy."

"I can learn to manage my thoughts better through therapy."

"I can use holistic approaches like meditation to help my symptoms."

"Many people have the same response to a stressful situation as I am having right"

"I am at high risk for post-traumatic-stress disorder because I have acute stress disorder"

"I will probably need to be on medication for the rest of my life."

Choice A rationale:
This order is useful to evaluate the client's electrolyte levels, renal function, and acid-base balance, as she has ERSD and missed her dialysis session. She may have hyperkalemia, metabolic acidosis, or uremia, which can affect her cardiac and neurological status.

Choice B rationale:
This order is helpful to assess the client's cardiac structure and function, as she has a history of CAD and HTN and may have developed heart failure or valvular disease.

Choice C rationale:
This order is beneficial to rule out any intra-abdominal causes of the client's nausea and poor appetite, such as infection, obstruction, or bleeding.

Choice D rationale:
This order is necessary to identify any possible source of infection or sepsis, as the client has been ill for 3 days and has a history of diabetes, which can impair her immune system.

Choice E rationale:
This order is important to assess the client's cardiac and pulmonary status, as she has a history of CAD and is presenting with chest discomfort and lightheadedness, which could indicate a cardiac event or pulmonary edema.

Choice F rationale:
This order is essential to monitor the client's heart rate and rhythm, as she has a history of CAD and HTN and is at risk for arrhythmias, ischemia, and infarction.

Choice G rationale:
This order is important to evaluate the client's hematological status, as she has ERSD and may have anemia, leukocytosis, or thrombocytopenia.

Choice H rationale:
This order is crucial to obtain a baseline of the client's cardiac electrical activity and to detect any signs of acute coronary syndrome, such as ST-segment elevation or depression, T wave inversion, or Q waves.

Choice A rationale:
This is not a priority action for the nurse at this time. The nurse should first implement the ordered treatments for hyperkalemia and stabilize the client's condition before calling and giving a report to the receiving unit.

Choice B rationale:
Loop diuretics are medications that increase urine output and can lower potassium levels in mild cases of hyperkalemia. However, they are contraindicated in patients with ERSD who have oliguria or anuria (reduced or absent urine production). Loop diuretics can worsen renal function and fluid overload in these patients.

Choice C rationale:
Scheduling the client for hemodialysis is crucial, especially if the client has missed a scheduled dialysis session. Hemodialysis can help manage electrolyte imbalances and fluid overload.

Choice D rationale:
Checking the blood glucose level is important, especially in a client with a history of diabetes. Maintaining glycemic control is essential for overall health.

Choice E rationale:
Drawing a repeat potassium level is necessary to monitor the client's electrolyte status, especially given the ECG changes.

Choice F rationale:
Holding Lisinopril, an ACE inhibitor, is appropriate in this context, considering the client's elevated blood pressure and potential renal issues. It should be done under the guidance of the healthcare provider.

Choice G rationale:
Administering insulin, dextrose, and calcium gluconate can help manage hyperkalemia, which may be indicated by the ECG changes. Repeating the 12-lead EKG is important to assess the response to treatment and any changes in cardiac rhythm.