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 B
Explanation
The correct answer is choice B. “You seem quite frightened right now.”.
Choice A rationale:
While reassuring the client that no one will hurt them is well-intentioned, it may not effectively address the client’s immediate emotional state or validate their feelings.
Choice B rationale:
Acknowledging the client’s fear helps validate their emotions and opens a pathway for further therapeutic communication. It shows empathy and understanding, which can help build trust and provide comfort.
Choice C rationale:
Telling the client they are in a safe place is reassuring, but it may not fully address the client’s immediate emotional distress or validate their feelings.
Choice D rationale:
Asking the client what they would like the nurse to do to protect them might reinforce the delusion and could potentially escalate the situation. It is more effective to acknowledge the client’s feelings and provide reassurance.
Correct Answer is C
Explanation
Choice A rationale:
Avocados and cheese are not specifically recommended for a client with a postoperative wound infection. While a balanced diet is important for overall health, yogurt or buttermilk is a better choice due to their probiotic content, which may promote gut health and support the immune system.
Choice B rationale:
Fresh fruits are generally a healthy dietary choice, but they are not particularly relevant to the management of a postoperative wound infection. The emphasis for this client should be on foods that support wound healing and immune function, such as yogurt or buttermilk.
Choice D rationale:
Green leafy vegetables are rich in vitamins and minerals, but they are not a primary focus for a client with a postoperative wound infection. Again, the emphasis should be on foods that support the immune system and overall recovery, such as yogurt or buttermilk.
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