Rn Hesi Mental Health
Rn Hesi Mental Health ( 38 Questions)
Patient Data
History and Physical Laboratory Results
Flow Sheet
Laboratory Test
Result
Glucose
75 mg/dL (4.2 mmol/L)
Reference Range
74 to 106 mg/dim (4.1 to 5.9 mmol/L)
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 was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month.
She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in her arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had a poor appetite and was not able to go for her scheduled dialysis 2
Initial vital signs: BP 146/82 mmHg, HR 114 bpm, RR 18 bpm, SpO, 98% on room air, temperature 98.2 °F (36.8 °C) orally.
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.