A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?
Increased urinary clearance of the multiple medications has produced diuresis and lowered blood pressure.
The synergetic effect of the multiple medication has resulted in drug toxicity and resulting hypotension.
The antagonistic interaction among the various blood pressure medications has reduced their effectiveness.
The additive effect of multiple medications has caused the blood pressure to drop too low.
The Correct Answer is D
The client is experiencing syncope (fainting) due to a drop in blood pressure to 70/40 mm Hg, which is too low. This suggests that the client's blood pressure medications are reducing their blood pressure too much, resulting in hypotension. The rationale for the nurse's decision to hold the client's scheduled antihypertensive medications is to prevent further hypotension and allow the client's blood pressure to stabilize at a safer level.
Option a is incorrect because diuresis (increased urine output) is not a likely cause of the client's hypotension.
Option b is incorrect because the client's symptoms suggest hypotension due to reduced blood pressure, rather than drug toxicity.
Option c is incorrect because the antagonistic interaction among blood pressure medications would result in reduced effectiveness but would not necessarily cause hypotension.
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Correct Answer is C
Explanation
The correct answer is C. Instruct the client to request assistance when ambulating to the bathroom.
Choice A reason:
Advise the client that the medication should start to work in about 30 minutes.
While it is important to inform the client about the onset of action of the medication, this is not the highest priority. Codeine, an opioid, can cause dizziness and sedation, which increases the risk of falls. Therefore, safety measures take precedence over informing the client about the medication’s onset time.
Choice B reason:
Administer a stool softener/laxative at the same time as the analgesic.
Opioids like codeine can cause constipation, so administering a stool softener or laxative is a good practice. However, this action is not the highest priority when considering the immediate safety of the client. Ensuring the client’s safety from potential falls due to dizziness or sedation is more urgent.
Choice C reason:
Instruct the client to request assistance when ambulating to the bathroom.
This is the correct answer because codeine can cause dizziness, sedation, and orthostatic hypotension, increasing the risk of falls. Ensuring the client requests assistance when moving can prevent potential injuries, making it the highest priority nursing action.
Choice D reason:
Tell the client to notify the nurse if the pain is not relieved.
While it is important for the client to communicate about the effectiveness of pain relief, this is not the highest priority. The immediate concern is the client’s safety due to the sedative effects of codeine. Therefore, preventing falls and injuries takes precedence.
Correct Answer is C
Explanation
The correct answer is C. Liver function lab results.
Choice A: Weight change in the last month
Weight change is a relevant factor to monitor in patients starting on antidepressants, including duloxetine, as some antidepressants can cause weight gain or loss. However, it is not the most critical information to obtain initially. Monitoring weight can help manage potential side effects and ensure the patient’s overall health, but it does not directly impact the immediate safety and efficacy of starting duloxetine.
Choice B: Recent use of other antidepressants
Recent use of other antidepressants is crucial information because combining duloxetine with other antidepressants, especially MAOIs (Monoamine Oxidase Inhibitors), can lead to serious interactions such as serotonin syndrome. This condition can be life-threatening and requires careful management. However, while this information is important, it is not as immediately critical as liver function tests when starting duloxetine.
Choice C: Liver function lab results
Liver function lab results are the most important information for the nurse to obtain. Duloxetine is metabolized in the liver, and patients with pre-existing liver conditions or impaired liver function are at higher risk for hepatotoxicity. Monitoring liver function is essential to prevent severe liver damage, which can be life-threatening. Baseline liver function tests help ensure that the patient can safely metabolize the medication and identify any potential issues early.
Choice D: Family history of mental illness
Family history of mental illness can provide valuable context for understanding the patient’s condition and potential genetic predispositions. It can also help in tailoring the treatment plan and anticipating the patient’s response to medication. However, while this information is useful for long-term management, it is not as immediately critical as liver function tests when initiating duloxetine therapy.
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