A client who is receiving a statin medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN takes priority?

Encourage the client to drink fluids.

Monitor the client's serum lipid levels.

Report the findings to the charge nurse.

Administer a PRN dose of acetaminophen.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C. Report the findings to the charge nurse. Choice A rationale:

Encouraging the client to drink fluids is not the priority in this situation. While hydration is important, the client's symptoms of muscle soreness, fatigue, and warm skin might indicate a potential adverse reaction to the statin medication, which requires immediate attention.

Choice B rationale:

Monitoring the client's serum lipid levels is not the priority at this moment. The client's current symptoms suggest a possible adverse reaction to the statin medication, and waiting for lipid level results may delay necessary interventions.

Choice C rationale:

Reporting the findings to the charge nurse is the priority action. The client's symptoms could be signs of rhabdomyolysis, a severe and potentially life-threatening condition where muscle breakdown releases toxic substances into the bloodstream. The charge nurse needs to be informed promptly so that appropriate interventions can be initiated.

Choice D rationale:

Administering a PRN dose of acetaminophen is not the priority in this situation. Acetaminophen may help with pain relief, but it will not address the potential underlying issue of muscle soreness and fatigue related to the statin medication.

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Correct Answer is A

Explanation

Glaucoma is a group of eye diseases that damage the optic nerve and cause vision loss. It is often associated with increased intraocular pressure, which can compress the nerve fibers and reduce blood ﬂow to the retina. The most common type of glaucoma, open-angle glaucoma, causes gradual loss of peripheral vision.

The other options are not correct because:

A. Macular edema is a condition that causes swelling and ﬂuid accumulation in the macula, the central part of the retina that is responsible for sharp and detailed vision. It can cause blurred or distorted vision, but it does not aﬀect the optic nerve or the peripheral vision.

B. Cataract is a condition that causes clouding of the lens, which is the transparent structure that focuses light onto the retina. It can cause blurred, dim, or yellowed vision, but it does not aﬀect the optic nerve or the intraocular pressure.

C. Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina and causes bleeding, leakage, or scarring. It can cause blurred, ﬂuctuating, or darkened vision, but it does not aﬀect the optic nerve or the intraocular pressure.

A. Thready pulse volume B. Missing pulse. C. Light pressure applied to pulse D. Pulse skips beats

Correct Answer is A

Explanation

A thready pulse is a weak and rapid pulse that is easily obliterated by light pressure. It indicates poor blood ﬂow and perfusion, and may be caused by conditions such as shock, dehydration, or hemorrhage.

The other options are not correct because:

A missing pulse is a pulse that is absent or cannot be detected, even with firm pressure. It indicates a complete blockage of blood ﬂow, and may be caused by conditions such as arterial occlusion, embolism, or trauma.
Light pressure applied to pulse is not a documentation of the pulse quality, but a description of the technique used to palpate the pulse.
Pulse skips beats is a documentation of an irregular pulse rhythm, not a pulse volume. It indicates that the heart beats are unevenly spaced, and may be caused by conditions such as arrhythmia, stress, or caﬀeine intake.

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A client who is receiving a statin medication reports the onset of muscle soreness and fatigue, and the practical nurse (PN) notes that the client's skin is warm to the touch. Which action by the PN takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is reviewing a client's recent ophthalmic screening test results. Findings of optic neuropathy, loss of peripheral vision, and increased intraocular pressure are consistent with which medical condition?

Correct Answer is A

Explanation

The practical nurse (PN) palpates a client's radial pulse and notes that the pulse disappears when light pressure is applied. How should the PN document this finding?

Correct Answer is A

Explanation

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