A nurse in a provider's office is caring for a client.
Nurses' Notes
3 months ago:
Client seen in provider's office for routine physical. Today:
Client reports dizziness and light-headedness upon standing. Client reports waking up at night to void.
What actions should the nurse take? Select all that apply.
Advise the client to change positions slowly.
Check the client for orthostatic hypotension. Monitor the client for dysrhythmias.
Advise the client to restrict potassium intake.
Advise the client to take the medication before bedtime.
Correct Answer : A,B
A. Advise the client to change positions slowly: The client's symptoms of dizziness and light- headedness upon standing suggest orthostatic hypotension, which can be managed by advising the client to change positions slowly to minimize blood pressure drops upon standing.
B. Check the client for orthostatic hypotension. Monitor the client for dysrhythmias: The client's symptoms, along with the report of waking up at night to void, are suggestive of orthostatic hypotension, a drop in blood pressure upon standing. Checking for orthostatic hypotension and monitoring for dysrhythmias are appropriate nursing actions to assess and manage this condition.
C. Advise the client to restrict potassium intake: Restricting potassium intake is not indicated based on the client's symptoms of dizziness and light-headedness. This action is not relevant to the situation described.
D. Advise the client to take the medication before bedtime: There is no indication in the scenario provided that medication timing is related to the client's symptoms. This action is not relevant to addressing the client's reported symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Peripheral edema: Peripheral edema is not a commonly reported adverse effect of paroxetine.
It is more commonly associated with medications such as calcium channel blockers and certain antihypertensive agents.
B. Alopecia: Alopecia, or hair loss, is not a commonly reported adverse effect of paroxetine. Hair loss is more commonly associated with certain chemotherapy agents and other medications.
C. Drowsiness: Drowsiness is a common side effect of paroxetine and other selective serotonin reuptake inhibitors (SSRIs). Clients should be advised to monitor for drowsiness, especially when starting the medication or adjusting the dosage. Drowsiness can affect activities such as driving or operating machinery and may indicate the need for dosage adjustment or medication change.
D. Tinnitus: Tinnitus, or ringing in the ears, is not a commonly reported adverse effect of paroxetine. It is more commonly associated with medications such as certain antibiotics (e.g., aminoglycosides) and high-dose aspirin.
Correct Answer is B
Explanation
A. Heart rate is important to monitor, but it is not the most immediate indicator of a life-threatening complication from midazolam. Changes in heart rate can occur, but they are usually secondary to respiratory issues.
B. Oxygen saturation is the priority because midazolam, a benzodiazepine, can cause respiratory depression and airway compromise. Monitoring oxygenation allows for rapid detection of hypoxia, which is the most immediate risk during moderate sedation.
C. Level of consciousness should be assessed, as midazolam causes sedation and can lead to oversedation. However, airway and breathing take priority over neurological assessment in this situation.
D. Temperature is not significantly affected by midazolam and is not an immediate concern during moderate sedation. It is therefore the lowest priority among the options provided.
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