The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?
Prolonged bleeding
Dry mucous membrane
Peaked T-waves
Polyuria
The Correct Answer is C
Choice A reason: Prolonged bleeding is not a direct indicator of hyperkalemia. It is more commonly associated with coagulation disorders or conditions affecting blood clotting.
Choice B reason: Dry mucous membranes are more indicative of dehydration rather than hyperkalemia. Dehydration can result from a variety of conditions but is not specific to high potassium levels.
Choice C reason: Peaked T-waves on an electrocardiogram (ECG) are a classic sign of hyperkalemia. Elevated potassium levels affect the cardiac conduction system, leading to characteristic changes in the ECG, such as tall, peaked T-waves, widened QRS complexes, and flattened P-waves.
Choice D reason: Polyuria (excessive urination) is not typically associated with hyperkalemia. It is more commonly seen in conditions like diabetes mellitus or diabetes insipidus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The statement "Because of the dysrhythmia, blood backs up in the legs and puts you at risk for blood clots" is incorrect. Atrial fibrillation primarily causes blood to pool in the atria, not the legs.
Choice B reason: The statement "Because the atria are quivering, blood flows sluggishly through them, and clots can form along the heart wall, which then could loosen and travel to the lungs or brain" accurately explains the risk of clot formation in atrial fibrillation and the importance of anticoagulant therapy to prevent strokes and other complications.
Choice C reason: The statement "The medications that you are taking cause blood clots as a side effect so you need this medication to prevent them" is incorrect. Anticoagulant therapy in atrial fibrillation is used to prevent clot formation due to the arrhythmia itself, not as a counteraction to the side effects of other medications.
Correct Answer is D
Explanation
Choice A reason: A high purine diet is more commonly associated with gout and hyperuricemia, not cholinergic crisis.
Choice B reason: A high protein diet is not directly related to cholinergic crisis. The crisis is related to medication levels rather than dietary factors.
Choice C reason: Not exercising enough is not a direct cause of cholinergic crisis. Physical activity levels do not impact the balance of acetylcholine in the body in this context.
Choice D reason: A cholinergic crisis occurs due to excessive accumulation of acetylcholine, often from taking too much of prescribed anticholinesterase medications. This can lead to overstimulation of the neuromuscular junction and symptoms such as muscle weakness and respiratory distress.
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