A female client who is admitted to the mental health unit for opiate dependency is receiving clonidine 0.1 mg by mouth (PO) for withdrawal symptoms.
The client begins to complain of feeling nervous and tells the nurse that her bones are itching.
Which finding should the nurse identify as a contraindication for administering the medication?
Hypertension.
Apical heart rate 72 beats/minute.
Muscle weakness.
Blood pressure 90/76 mm Hg.
The Correct Answer is D
The correct answer is Choice D.
Choice A rationale:
Hypertension is not a contraindication for administering clonidine. In fact, clonidine is often used to treat hypertension. It works by decreasing the levels of certain chemicals in your blood, allowing your blood vessels to relax and your heart to beat more slowly and easily.
Choice B rationale:
An apical heart rate of 72 beats/minute is within the normal range (60-100 beats/minute) and would not be a contraindication for administering clonidine. Clonidine can lower heart rate, so it’s important to monitor heart rate, but a normal heart rate does not preclude its use.
Choice C rationale:
Muscle weakness is not a specific contraindication for the use of clonidine. While muscle weakness can be a side effect of many medications, it is not typically associated with clonidine. However, if a patient was experiencing severe or unusual muscle weakness, it would be important for the healthcare provider to evaluate this symptom.
Choice D rationale:
A blood pressure of 90/76 mm Hg could be a contraindication for the use of clonidine. Clonidine is a medication that is used to lower blood pressure, and if a patient’s blood pressure is already low, further lowering it could lead to symptoms such as dizziness, fainting, or even shock. Therefore, it would be important to monitor the patient’s blood pressure closely while they are taking this medication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The neurology unit supervisor is not the most appropriate nurse to coordinate the progression of care for a client with a spinal cord injury (SCI). While they may have expertise in neurology, the nurse case manager is specifically trained to coordinate and manage the care of patients with complex conditions, including SCI. They can facilitate communication between various healthcare providers and ensure that the client receives comprehensive care throughout their stay.
Choice B rationale:
An adult nurse practitioner may have specialized knowledge in the care of adults, but they may not have the specific skills and training required to coordinate the care of a client with a spinal cord injury in the ICU. Nurse case managers are better equipped to manage complex cases and ensure the continuity of care for the client.
Choice D rationale:
A risk management nurse focuses on minimizing healthcare-related risks and ensuring the safety of patients and staff. While their role is essential, it is not the primary responsibility to coordinate the progression of care for a client with a spinal cord injury. The nurse case manager is better suited for this role as they specialize in care coordination.
Correct Answer is D
Explanation
Choice A rationale:
Concerns about parenting. While concerns about parenting are important to address during prenatal care, the initial visit focuses on gathering essential information and providing education related to pregnancy and childbirth. Knowledge about labor and delivery is crucial for the client to understand the process and make informed decisions.
Choice B rationale:
Cultural practices related to childbearing. Cultural practices related to childbearing are also essential topics to discuss during prenatal care, but they may not be the highest priority at the initial visit. Understanding the client's cultural background and beliefs is important, but providing information about pregnancy and childbirth should take precedence during the first prenatal visit.
Choice C rationale:
Complications associated with childbirth. Discussing complications associated with childbirth is important, but it may be overwhelming for a client during the initial prenatal visit. The primary focus should be on providing basic information and addressing immediate questions and concerns, with more in-depth discussions about complications occurring in subsequent visits.
Choice D rationale:
Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.
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