Case Study
Rn Hesi Mental Health Proctored Exam
Select All That Apply
Exhibits Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse. The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with: Fatigue Generalized weakness Muscle cramps Tingling sensation in her arms and legs Lightheadedness She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions. Initial Vital Signs: Blood Pressure: 146/82 mmHg Heart Rate: 114 bpm Respiratory Rate: 18 bpm SpO₂: 98% on room air Temperature: 98.2 °F (36.8 °C) orally
Explanation & Rationale
The assessment findings that require immediate follow-up by the nurse are: muscle cramps, tingling sensation in arms and legs, and lightheadedness. These are signs of electrolyte imbalance, which can be caused by missed dialysis sessions, dehydration, or infection. Electrolyte imbalance can lead to serious complications such as cardiac arrhythmias, seizures, or coma. The nurse should monitor the client's vital signs, neurological status, and cardiac rhythm, and notify the physician for further orders. The nurse should also assess the client's fluid status, hydration, and nutritional intake, and provide education on the importance of adhering to the dialysis schedule and dietary restrictions.
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