The nurse is caring for a patient who is experiencing disequilibrium syndrome during hemodialysis. Which of the following interventions will the nurse implement for this patient? (Select All That Apply)
Administer a rapid infusion of fluids.
Increase the dialysis flow rate.
Decrease the rate of dialysis.
Apply ice packs to the patient's head.
Monitor neurological status closely.
Correct Answer : C
Choice A reason: Administering a rapid infusion of fluids is not appropriate for disequilibrium syndrome. This syndrome results from rapid changes in fluid and electrolyte balance during dialysis, and rapid fluid infusion could worsen the condition.
Choice B reason: Increasing the dialysis flow rate is not appropriate. Decreasing the rate of dialysis can help reduce the symptoms of disequilibrium syndrome by allowing the body to adjust more gradually.
Choice C reason: Decreasing the rate of dialysis helps to minimize the rapid shifts in fluid and electrolytes, which can exacerbate disequilibrium syndrome.
Choice D reason: Applying ice packs to the patient's head is not a standard intervention for disequilibrium syndrome. The focus should be on managing the rate of dialysis and monitoring the patient's neurological status.
Choice E reason: Monitoring neurological status closely is important because disequilibrium syndrome can cause symptoms such as headache, nausea, confusion, and seizures. Close monitoring allows for prompt intervention if symptoms worsen.
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Correct Answer is ["C"]
Explanation
Choice A reason: Administering a rapid infusion of fluids is not appropriate for disequilibrium syndrome. This syndrome results from rapid changes in fluid and electrolyte balance during dialysis, and rapid fluid infusion could worsen the condition.
Choice B reason: Increasing the dialysis flow rate is not appropriate. Decreasing the rate of dialysis can help reduce the symptoms of disequilibrium syndrome by allowing the body to adjust more gradually.
Choice C reason: Decreasing the rate of dialysis helps to minimize the rapid shifts in fluid and electrolytes, which can exacerbate disequilibrium syndrome.
Choice D reason: Applying ice packs to the patient's head is not a standard intervention for disequilibrium syndrome. The focus should be on managing the rate of dialysis and monitoring the patient's neurological status.
Choice E reason: Monitoring neurological status closely is important because disequilibrium syndrome can cause symptoms such as headache, nausea, confusion, and seizures. Close monitoring allows for prompt intervention if symptoms worsen.
Correct Answer is A
Explanation
Choice A reason: Hypotension, or low blood pressure, is a common indicator of fluid volume deficit. When a patient is dehydrated or has a significant loss of fluids, their blood volume decreases, leading to lower blood pressure. This condition requires immediate attention and management to prevent complications such as shock or organ failure. Monitoring and correcting fluid balance is crucial in managing patients with diabetic ketoacidosis, making hypotension a significant assessment finding.
Choice B reason: Bradycardia, or slow heart rate, is not typically associated with fluid volume deficit. It is more often related to other conditions such as heart block, hypothyroidism, or use of certain medications. In the context of diabetic ketoacidosis, fluid volume deficit would not manifest primarily as bradycardia.
Choice C reason: Polyphagia, or excessive hunger, is a symptom commonly associated with diabetes mellitus but does not indicate fluid volume deficit. Polyphagia results from the body's inability to use glucose properly, leading to increased hunger. It is not directly related to the patient's hydration status or fluid volume.
Choice D reason: Rapid, deep respiration, also known as Kussmaul breathing, is a compensatory mechanism in response to metabolic acidosis, a hallmark of diabetic ketoacidosis. While it is an important clinical sign, it does not specifically indicate fluid volume deficit. Kussmaul respiration occurs due to the body's attempt to expel excess carbon dioxide and correct the acid-base imbalance.
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