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When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client's laboratory values to validate the existence of which condition?
- A. Hyperphosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct Answer: D
Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client's laboratory values for potassium levels will help confirm the presence of hypokalemia.
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A client with a suspected kidney infection is admitted to the hospital for observation. Which action should the nurse implement to assess the client's kidney function?
- A. Monitor the client's urine output
- B. Check for abdominal tenderness
- C. Evaluate the client's fluid intake
- D. Inspect the client's skin for edema
Correct Answer: A
Rationale: Monitoring urine output is the most direct way to assess kidney function as it provides crucial information about the kidneys' ability to filter waste and produce urine. Changes in urine output can indicate potential issues with kidney function, such as decreased filtration or impaired excretion of waste products.
The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?
- A. Performing ROM exercises during bathing.
- B. Changing the patient's position every two hours.
- C. Suctioning the patient supine and tightly pulling the bed sheets across their feet.
- D. Placing the patient in the prone position for one hour three times a day.
Correct Answer: C
Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.
When making the bed of a client who needs a bed cradle, which action should the nurse include?
- A. Teach the client to call for help before getting out of bed.
- B. Keep both the upper and lower side rails in a raised position.
- C. Keep the bed in the lowest position while changing the sheets.
- D. Drape the top sheet and covers loosely over the bed cradle.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which nonverbal action should be implemented to demonstrate active listening?
- A. Sit facing the individual.
- B. Cross arms and legs.
- C. Avoid eye contact.
- D. Lean back in the chair.
Correct Answer: A
Rationale: To demonstrate active listening effectively, it is essential to display open and engaging body language. Sitting facing the individual helps convey attentiveness and a willingness to listen. Maintaining eye contact further enhances the connection and shows respect and interest in the conversation. Crossing arms and legs can create a barrier and signal defensiveness or disinterest. Avoiding eye contact may suggest a lack of engagement or attentiveness. Leaning back in the chair can indicate relaxation but might be perceived as disengagement. Therefore, the most appropriate nonverbal action to demonstrate active listening is to sit facing the individual and maintain eye contact.
While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
- A. Encourage the client to see the clinic's grief counselor.
- B. Determine if the client has a family history of suicide attempts.
- C. Inquire about whether the life partner had AIDS.
- D. Consult with the healthcare provider about the client's need for antidepressant medications.
Correct Answer: A
Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.