The nurse is caring for a client with elevated parathyroid hormone levels. Which safety precaution should the nurse include in the plan of care?
Hypothermia.
Aspiration.
Falls.
Suicide.
The Correct Answer is C
Choice A reason: Hypothermia is not typically associated with hyperparathyroidism and does not require specific precautions in this context.
Choice B reason: Aspiration may be a concern for patients with severe hypercalcemia if they have altered mental status, but it is not the primary safety precaution.
Choice C reason: Falls are a significant risk due to potential muscle weakness, skeletal fragility, and possible neuromuscular symptoms caused by hypercalcemia.
Choice D reason: Suicide is not directly related to hyperparathyroidism; however, mental health should always be monitored in patients with chronic conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.
Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.
Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.
Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.
Correct Answer is C
Explanation
Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.
Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.
Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.
Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.
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