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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: While it is important to monitor the fetal heart rate, it does not directly address the client's immediate need to empty her bladder.
Choice B rationale: Obtaining a straight catheter kit to empty her bladder could be considered if the client is unable to void on her own, but it is not the first line of action if the client is able to ambulate.
Choice C rationale: Checking the perineum for changes in "show" or discharge is part of ongoing labor monitoring, but it does not address the client's immediate request.
Choice D rationale: Assisting the client up to the bathroom is appropriate. Ambulating to the bathroom is safe given the unchanged vaginal exam, and allowing the client to empty her bladder can help maintain bladder function and comfort.
Correct Answer is D
Explanation
The correct answer is Choice d. Powerful craving for more.
Rationale:
Cocaine withdrawal symptoms are primarily psychological and emotional, rather than physical. While some physical symptoms may occur, such as fatigue and muscle aches, the most prominent and concerning aspects of withdrawal are intense cravings for the drug.
Here's a breakdown of the other choices and why they are not as likely:
- Choice a. Elevated energy level:Cocaine is a stimulant,so during withdrawal,a person is more likely to experiencedecreased energy and fatigue.
- Choice b. High self-esteem:Cocaine use can initially boost self-esteem,but withdrawal often leads to feelings ofdepression, anxiety, and worthlessness.
- Choice c. Euphoria:Euphoria is one of the main effects of cocaine use,but during withdrawal,the opposite occurs,with individuals experiencingdysphoria, a state of intense negative emotions.
Therefore, the intense craving for more cocaine is the most characteristic behavioral symptom exhibited during cocaine withdrawal. This craving is driven by the brain's adaptation to the drug's presence and the disruption of dopamine and other neurotransmitter systems caused by withdrawal.
Additional Notes:
- The intensity of cocaine withdrawal symptoms can vary depending on several factors,including the severity and duration of cocaine use,individual differences in brain chemistry and genetics,and the presence of co-occurring mental health conditions.
- Seeking professional help for cocaine withdrawal is crucial to manage cravings and other symptoms effectively and increase the chances of successful recovery.
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