A patient had minor surgery and is now ambulating frequently. The patient has been perspiring profusely, is apprehensive, lethargic, and confused, and is complaining of a headache and muscle weakness
These findings are most consistent with which electrolyte disturbance? a. hypokalemia c. hyponatremia
b. hyperkalemia d. hypernatremia
C
Hyponatremia is associated with headaches, apprehension, lethargy, confusion, depression, and convulsions. Hypernatremia is associated with restlessness, agitation, delirium, twitching, convulsions, and coma. Hypokalemia is associated with decreased bowel sounds, abdominal distention, paralytic ileus, nausea, and vomiting. Hyperkalemia is associated with nausea, muscle cramps, pain, and diarrhea.
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The nurse interviewing an older adult for a nursing history recognizes that the client is experiencing symptomology inconsistent with normal aging of the urinary tract when the client reports: Select all that apply
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While performing a morning assessment on a terminally ill patient, the nurse observes a generalized purplish blotching of the patient's skin. The nurse identifies this finding as
1. Mottling 2. Maceration 3. Excoriation 4. Evisceration
In a long-term care setting, a nurse should do which of the following to help promote mobility in a patient's home? Select all that apply
1. Use the continuous passive motion (CPM) machine. 2. Evaluate the patient's need for physical therapy. 3. Ambulate joints beyond 90 degrees as quickly as possible. 4. Follow activity orders. 5. Encourage the patient to lie down as much as possible.
You observe a student nurse who is caring for a client who has an intracavitary radioactive implant in place to treat cervical cancer. Which action by the student requires that you intervene immediately?
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