A client who is taking methylprednisolone reports feeling thirsty. Which action should the nurse take first?
Monitor urinary output.
Notify the healthcare provider (HCP).
Prepare to give insulin.
Obtain fingerstick blood glucose.
The Correct Answer is D
A. Monitor urinary output: While monitoring output is important, it does not provide immediate diagnostic information regarding the cause of the client’s thirst. It is a supportive action but not the most efficient first step to investigate potential hyperglycemia.
B. Notify the healthcare provider (HCP): Notifying the HCP is appropriate if there are abnormal findings or the client’s condition worsens. However, the nurse should gather objective data—such as a blood glucose reading—before contacting the provider.
C. Prepare to give insulin: Insulin should not be administered without confirmation of elevated blood glucose. Giving insulin without verifying hyperglycemia could lead to serious complications, including hypoglycemia.
D. Obtain fingerstick blood glucose: Methylprednisolone, a corticosteroid, can raise blood glucose levels, and excessive thirst is a classic symptom of hyperglycemia. Checking the client’s blood glucose is the most appropriate first action to determine if elevated glucose is causing the symptom.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature of 100.8° F (38.2° C): A mildly elevated temperature in a post-transplant client may suggest infection or early rejection, both of which warrant monitoring. However, this is not a direct reason to withhold cyclosporine, which is essential for preventing organ rejection.
B. Elevated blood urea nitrogen (BUN): Elevated BUN could indicate impaired renal function, which should be monitored during cyclosporine therapy. However, this alone is not an urgent reason to withhold the medication without further evaluation of kidney function trends and symptoms.
C. Renal output of 120 mL/hour: This is a healthy urine output and suggests good renal perfusion and function. It does not present any contraindication to continuing cyclosporine and supports that the transplanted kidney is functioning well.
D. Blood pressure 180/98 mm Hg: Hypertension is a known side effect of cyclosporine and can become severe. A blood pressure this high, especially when accompanied by headache and blurred vision, suggests possible cyclosporine-induced hypertensive crisis or toxicity, and warrants immediate withholding of the medication and notification of the HCP.
Correct Answer is ["B","D","E"]
Explanation
A. Describe how anabolic steroids increase muscle strength to improve athletic performance: While anabolic steroids do enhance muscle mass and strength, emphasizing this could inadvertently normalize or encourage their misuse rather than addressing the serious health risks involved.
B. Advise of the need to observe for changes in behavior, such as increased aggression: Anabolic steroids can cause mood disturbances, including aggression, irritability, and even psychiatric symptoms. Educating the parent to monitor for behavioral changes is critical for early intervention.
C. Explain that this is a schedule II controlled substance: Anabolic steroids are actually classified as Schedule III controlled substances under the Controlled Substances Act, not Schedule II. Providing inaccurate information could lead to confusion and mismanagement of the situation.
D. Encourage a clinic visit to assess the adolescent for cardiovascular complications: Steroid use can increase the risk of serious cardiovascular problems like hypertension, lipid abnormalities, and myocardial damage. Prompt medical evaluation is essential to detect early complications.
E. Identify the use of any other herbal supplements: Adolescents who misuse anabolic steroids may also be using other supplements or substances that could have dangerous interactions. A full assessment of all substances being used is important for comprehensive care and counseling.
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