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The nurse is caring for a client with end-stage renal disease (ESRD) who is anuric and receives hemodialysis three times a week. During a routine assessment, the patient expresses frustration about strict fluid restrictions and states, “I don’t even make urine anymore, so why does it matter how much I drink?” Which of the following is the most appropriate response by the nurse?

Because your kidneys no longer produce urine, fluid can build up quickly and lead to complications like high blood pressure or difficulty breathing

You should actually drink more fluids to stay hydrated since you’re not urinating

As long as you’re attending all your dialysis sessions, your fluid intake doesn’t need to be restricted

It’s not the fluids that are harmful, it’s the foods that are high in potassium and phosphorus

Answer and Explanation

The Correct Answer is A

Choice A reason: In ESRD, anuria means no urine output, so excess fluid accumulates in the body, increasing intravascular volume. This can cause hypertension, pulmonary edema, and respiratory distress. Educating the client about these risks emphasizes the importance of fluid restrictions to prevent life-threatening complications between dialysis sessions, addressing their frustration accurately.

Choice B reason: Advising increased fluid intake is incorrect for anuric ESRD patients, as their kidneys cannot excrete fluid. This would exacerbate fluid overload, leading to hypertension, heart failure, or pulmonary edema. Hydration is managed through dialysis, not increased oral intake, which could overwhelm the body’s limited fluid-handling capacity.

Choice C reason: Stating that fluid intake is unrestricted with dialysis is incorrect. Even with regular dialysis, excessive fluid intake between sessions can lead to overload, causing hypertension or pulmonary edema. Dialysis removes a limited amount of fluid per session, requiring strict restrictions to maintain safe fluid balance and prevent complications.

Choice D reason: While potassium and phosphorus restrictions are critical in ESRD to prevent hyperkalemia and hyperphosphatemia, the client’s question focuses on fluid restrictions. This response does not address fluid overload risks like hypertension or pulmonary edema, which are direct consequences of excessive fluid intake in anuric patients, making it irrelevant to the query.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Choice A reason: One-to-one observation for aggressive behavior is a standard safety measure to prevent harm, aligning with the right to safe care. It does not violate client rights when justified by clinical need, as it prioritizes protection without restricting autonomy unnecessarily, making it an appropriate intervention.

Choice B reason: Using physical restraints to prevent self-harm is permissible when less restrictive measures fail, aligning with the right to safety. If properly documented and justified, it does not violate rights, as mental health laws allow restraints for imminent danger, making this action compliant with client rights.

Choice C reason: Searching belongings at admission is standard in psychiatric settings to ensure safety (e.g., removing contraband). This practice, when conducted respectfully and per policy, does not violate client rights, as it prioritizes a safe therapeutic environment for all patients and staff on the unit.

Choice D reason: Lack of documentation of treatment benefits and options violates the right to informed consent. Clients must be informed about treatment rationale and alternatives to make autonomous decisions. Failure to document this breaches legal and ethical standards, undermining the client’s ability to participate in their care, making it a rights violation.

A. Behavior that may be viewed as acceptable in one culture yet unacceptable in other cultures B. Mental health is a state of emotional, psychological, and social wellness evidenced by use of positive coping strategies C. Persons who engage in fantasies are mentally ill D. It is easy to determine if a person is mentally healthy or mentally ill by monitoring one’s verbal and nonverbal communication

Correct Answer is B

Explanation

Choice A reason: While behavior acceptability varies across cultures, this statement does not fully define mental health or illness. Cultural norms influence behavior interpretation, but mental health involves emotional and psychological well-being, not just cultural acceptability, making this option incomplete as a definition of mental health or illness.

Choice B reason: Mental health is characterized by emotional, psychological, and social well-being, reflected in adaptive coping strategies like problem-solving or seeking support. This holistic state enables individuals to manage stress and function effectively, making this statement a comprehensive and accurate description of mental health in contrast to mental illness.

Choice C reason: Engaging in fantasies is not inherently indicative of mental illness, as it can be a normal part of creativity or coping. Only when fantasies disrupt functioning or reflect delusions does it suggest illness. This statement is inaccurate, as it overgeneralizes a common behavior as pathological.

Choice D reason: Determining mental health or illness via verbal and nonverbal communication is complex and not always reliable. Cultural, individual, and contextual factors obscure interpretation, and clinical assessment requires comprehensive evaluation beyond communication, making this statement inaccurate as a definitive method for assessing mental health status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing an electronic medical record to determine if a client’s rights have been violated by another member of the healthcare team. Which finding will the nurse identify that would indicate a violation of the client’s rights?

Correct Answer is D

Explanation

Which of the following is true regarding mental health and mental illness?

Correct Answer is B

Explanation

The nurse is receiving the morning report on four clients on a medical-surgical unit. Based on the information provided, which clients are at greatest risk for developing end-stage renal disease (ESRD)? (Select all that apply)

A nurse is planning the discharge of a client with a mental health disorder. Which factor does the nurse identify as the best chance for the client to remain in the community without readmission?

The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

A nurse and client are engaged in a discussion. The client says, “I feel really close to you. You are my only true friend.” Which response by the nurse would be most therapeutic?

When is a nurse legally obligated to breach confidentiality?

A client is fearful and reluctant to talk after a traumatic event. Which technique will the nurse employ that is most effective when trying to engage the client in interaction?

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should: