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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Preparing for the administration of IV fluids is important but not as immediate as administering a bolus of IV fluids. Immediate fluid resuscitation is crucial for addressing low blood pressure and improving the patient's hemodynamic status.

Choice B reason: Administering a bolus of IV fluids is the priority nursing action for a patient with symptomatic hypotension. Rapid fluid administration helps to increase blood volume and improve blood pressure, which is essential for stabilizing the patient.

Choice C reason: Administering Atenolol, a beta-blocker, is not appropriate for a patient with hypotension. Beta-blockers can further lower blood pressure and are contraindicated in this situation.

Choice D reason: Administering Nitroglycerin is not suitable for a patient with hypotension. Nitroglycerin can cause vasodilation and further decrease blood pressure, which would worsen the patient's condition.

A. Teach the client about using hats and scarves to cover hair loss B. Explain that hair loss is a temporary side effect of chemotherapy C. Provide resources for wigs and other head coverings D. Recommend limiting social interactions to avoid embarrassment

Correct Answer is C

Explanation

Choice A reason: Teaching the client about using hats and scarves is helpful, but providing resources for wigs and head coverings offers more comprehensive support and options.

Choice B reason: Explaining that hair loss is a temporary side effect of chemotherapy is informative but does not directly address the client's distress.

Choice C reason: Providing resources for wigs and other head coverings directly addresses the client's concern about hair loss. It offers practical solutions and helps the client cope with the physical changes caused by chemotherapy.

Choice D reason: Recommending limited social interactions to avoid embarrassment is not supportive. It may increase feelings of isolation and does not address the underlying distress.

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The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?

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Naxlex Comprehensive Predictor Exams

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