The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Monitor the client.

Elevate the head of the bed.

Assess the fistula site and dressing.

Notify the primary health care provider (PHCP).

Answer and Explanation

The Correct Answer is D

Choice A reason: Monitoring is important but doesn’t address the urgency of headache, nausea, and restlessness, suggesting disequilibrium syndrome. Notifying the provider is critical, making this incorrect, as it delays the nurse’s priority action to manage a serious post-dialysis complication.

Choice B reason: Elevating the head of the bed may help comfort but doesn’t treat potential disequilibrium syndrome indicated by headache and restlessness. Notifying the provider is urgent, making this incorrect, as it’s less critical than the nurse’s need to report symptoms.

Choice C reason: Assessing the fistula site is routine but unrelated to headache and nausea, which suggest a neurological issue. Notifying the provider takes precedence, making this incorrect, as it’s not the priority compared to addressing potential post-dialysis complications.

Choice D reason: Notifying the provider is the priority for headache, nausea, and restlessness post-hemodialysis, as these suggest disequilibrium syndrome, a serious complication. This aligns with dialysis care protocols, making it the correct action for the nurse to take immediately.

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Correct Answer is B

Explanation

Choice A reason: A low-fat diet benefits gallbladder issues, not acute diverticulitis, which requires reduced bowel stimulation. A low-fiber diet prevents irritation, making this incorrect, as it’s less relevant than the nurse’s anticipated prescription for managing acute diverticulitis symptoms effectively.

Choice B reason: A low-fiber diet is prescribed for acute diverticulitis to rest the colon and reduce irritation of inflamed diverticula. This aligns with gastrointestinal treatment protocols, making it the correct diet the nurse would anticipate for the client’s acute diverticulitis management.

Choice C reason: A high-protein diet supports healing but isn’t specific for acute diverticulitis, which needs low fiber to avoid irritation. Low-fiber is correct, making this incorrect, as it’s not the primary diet the nurse expects for managing acute diverticulitis symptoms.

Choice D reason: A high-carbohydrate diet may increase bowel activity, worsening acute diverticulitis. A low-fiber diet reduces stimulation, making this incorrect, as it’s inappropriate compared to the nurse’s anticipated prescription for a diet to manage acute diverticulitis effectively.

A. Increased urine output. B. Persistent diarrhea. C. Hypotension. D. Tachycardia.

Correct Answer is C

Explanation

Choice A reason: Increased urine output is not typical in untreated hypothyroidism, which slows metabolism and fluid balance. Hypotension from reduced cardiac output is expected, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in a client non-compliant with hypothyroidism therapy.

Choice B reason: Persistent diarrhea is more associated with hyperthyroidism, not hypothyroidism, which causes constipation. Hypotension is a common finding in untreated hypothyroidism, making this incorrect, as it contradicts the expected symptoms in the nurse’s assessment of the non-compliant client.

Choice C reason: Hypotension is expected in untreated hypothyroidism due to decreased metabolic rate and cardiac output. This aligns with endocrine assessment findings, making it the correct finding the nurse would anticipate in a client who hasn’t taken thyroid replacement medication regularly.

Choice D reason: Tachycardia is typical in hyperthyroidism, not hypothyroidism, which causes bradycardia. Hypotension is more consistent with untreated hypothyroidism, making this incorrect, as it doesn’t reflect the slowed metabolism expected in the nurse’s evaluation of the non-compliant client.

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The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of gastrointestinal upset has been diagnosed with acute diverticulitis. The nurse would anticipate a prescription from the primary health care provider for which type of diet for this client?

Correct Answer is B

Explanation

A home health nurse is assessing a client who requires lifelong replacement hormone therapy for hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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