The practical nurse (PN) identifies an electrolyte imbalance, an elevated blood pressure, and exhibited changes in mental status for a client with acute kidney injury (AKI). Which intervention in the plan of care should the PN implement?
Discuss a low sodium diet.
Provide only distilled water.
Monitor for dependent pitting edema.
Use a cushion when sitting.
The Correct Answer is C
A. Discuss a low sodium diet: While teaching about a low sodium diet is important in managing fluid balance and hypertension, it is not the immediate intervention needed to address the acute symptoms and risks associated with the client's current condition.
B. Provide only distilled water: Distilled water is not necessary in managing acute kidney injury. Fluid intake management should be based on specific electrolyte and fluid needs, and the focus should be on controlling volume overload rather than the type of water provided.
C. Monitor for dependent pitting edema: Monitoring for pitting edema is critical because it provides immediate information about fluid overload, which is common with acute kidney injury. Assessing for edema provides information about the extent of fluid retention and helps evaluate the effectiveness of interventions aimed at managing fluid balance.
D. Use a cushion when sitting: Using a cushion may improve comfort but does not address the life-threatening complications of electrolyte imbalance, hypertension, and mental status changes associated with acute kidney injury. Priority should be on assessing and managing systemic symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
A. Show acceptance of the client's current feelings: Accepting the client’s emotional response without judgment builds trust and provides emotional support, which is critical when coping with a new diagnosis of advanced cancer.
B. Share a similar personal experience: Sharing personal experiences shifts the focus away from the client’s feelings and can be perceived as minimizing their unique emotional response. It is more therapeutic to focus entirely on the client’s experience.
C. Document the behavior in the client's record: Accurate documentation of the client's emotional state ensures continuity of care and alerts other healthcare providers to the client's need for emotional support and potential interventions.
D. Ask the palliative care nurse to see the client: Involving a palliative care specialist provides expert emotional, spiritual, and symptom management support, which is appropriate for a client newly diagnosed with stage IV cancer.
E. Allow the client a time to continue crying: Allowing the client to cry acknowledges their need to express grief and emotion. It helps the client begin processing the overwhelming news and supports healthy emotional expression.
Correct Answer is C
Explanation
A. Acknowledge the client's concerns and notify the healthcare provider of the client's wishes: While it is important to acknowledge the client's feelings, immediately notifying the healthcare provider is not the first or most critical action. The client first needs a clear explanation of the purpose of the advance directive.
B. Ask a family member to describe the client's stated wishes regarding end-of-life care: Involving family members at this stage may undermine the client's autonomy. The focus should be on informing and empowering the client to make his own decisions.
C. Explain that the form identifies his personal health care wishes for any future event: It is important to clarify that advance directives are not just for those who are dying but help ensure that healthcare decisions align with the client’s wishes if he becomes unable to communicate in the future. Clear communication can ease misunderstandings and support informed decision-making.
D. Document his refusal in his electronic medical record using his exact words: While documentation is important, it should occur after ensuring that the client fully understands the purpose of the form. Providing education first supports client rights and informed consent.
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