A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

Do not take any over-the-counter medications.

Eat a high carbohydrate, low fat, low protein diet.

Call the crisis hot line if feeling lonely.

Avoid exposure to large crowds.

Answer and Explanation

The Correct Answer is A

A.   Do not take any over-the-counter medications. This is crucial because many over-the-counter medications, including those containing acetaminophen, can further damage the liver. Avoiding these medications is essential to prevent further hepatic injury.
B.   Eat a high carbohydrate, low fat, low protein diet. While diet can influence liver health, this specific dietary advice is less critical than preventing further liver damage from medications.
C.   Call the crisis hot line if feeling lonely. This is important for mental health support, but the immediate physical health concern related to liver damage takes precedence.
D.   Avoid exposure to large crowds. This may be relevant if the client is immunocompromised due to liver damage, but it is not as directly related to preventing further liver injury as avoiding certain medications.

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Correct Answer is C

Explanation

A. Encouraging the client to participate in a team sport may be overwhelming and unrealistic given the client's current level of depression and lack of activity. Starting with smaller, more achievable goals is essential in the initial stages of treatment.

B. Helping the client develop a list of daily affirmations is a positive intervention for promoting self-esteem, but it may not address the immediate need for increasing activity levels or engagement in meaningful activities.

C. Assisting the client in identifying goals for the day is the most important intervention at this stage. Setting achievable daily goals can help the client regain a sense of purpose and motivation. These goals should be realistic and tailored to the client's current abilities and interests.

D. Scheduling the client for a group focusing on self-esteem is beneficial, but it may not directly address the client's need for increased activity and engagement in meaningful daily activities.
Goals related to self-esteem can be incorporated into the client's plan of care but should be part of a comprehensive approach to treatment.

A. Explain that temporary burning at the IV site may occur. B. Apply a topical anesthetic at the infusion site for burning. C. Assess IV site frequently for signs of extravasation. D. Monitor capillary refill distal to the infusion site.

Correct Answer is C

Explanation

A. Explaining that temporary burning at the IV site may occur is important for informing the client about potential side effects but does not address the specific risk associated with vesicant chemotherapeutic agents.

B. Applying a topical anesthetic at the infusion site for burning is not typically indicated during the administration of vesicant chemotherapeutic agents. While it may provide some comfort, it does not address the risk of extravasation.

C. Assessing the IV site frequently for signs of extravasation is essential during the administration of vesicant chemotherapeutic agents. Vesicants can cause tissue necrosis and damage if they leak into surrounding tissues. Early detection of extravasation allows for prompt intervention to minimize tissue damage.

D. Monitoring capillary refill distal to the infusion site is important for assessing peripheral perfusion but does not specifically address the risk of extravasation associated with vesicant chemotherapeutic agents.

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A male adult is admitted because of an acetaminophen overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client's discharge plan?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Which intervention should the nurse implement during the administration of a vesicant chemotherapeutic agent via an intravenous (IV) site in the client's arm?

Correct Answer is C

Explanation

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