The nurse is performing an assessment on a client who has returned from dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. What is the priority nursing action?
A. Monitor the client.
B. Elevate the head of bed.
C. Assess the fistula site and dressing.
D. Notify the Primary Health Care Provider.
What is D? Notify the PHCP.
Rationale: Disequilibrium syndrome may be caused by rapid removal of solutes from the body during hemodialysis. These changes can cause cerebral edema that leads to increased intracranial pressure. The client is exhibiting early signs and symptoms of disequilibrium syndrome, and appropriate treatments with anticonvulsant and barbiturates may be necessary to prevent a life threatening situations. The PHCP must be notified first. Monitoring the client, elevating HOB, and assessing the fistula site are correct action, but the priority action is notify the PHCP.
The older client with BPH and hypertension is being treated with doxazosin (Cardura) while staying in the hospital. Which should the nurse monitor for following the first dose? A. Increased heart rate and shortness of breath B. Orthostatic hypotension and syncope C. Prolonged erection and loss of appetite D. Drowsiness and temporary memory loss
What is B (orthostatic hypotension and syncope)?