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A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply)(Select All that Apply.)

Damp dressing

Warmth at insertion site

Streak formation

Throbbing

Erythema

Answer and Explanation

Correct Answer : B,C,D,E

Answer: (B, C, D, E)

Rationale:

A) Damp dressing: A damp dressing around the IV site is typically indicative of a leaking IV or infiltration, where fluid escapes from the vein into the surrounding tissue. This finding is not directly related to phlebitis, which is inflammation of the vein.

B) Warmth at insertion site: Warmth at the insertion site is a common sign of phlebitis. The inflammation of the vein causes increased blood flow to the area, leading to localized warmth. This symptom is a key indicator that the IV site may be irritated or infected.

C) Streak formation: Streak formation, often seen as a red line running along the vein above the IV site, is a classic sign of phlebitis. It indicates inflammation and irritation spreading along the vein, which can occur due to the presence of the IV catheter.

D) Throbbing: Throbbing pain or discomfort at the IV site is another sign of phlebitis. The inflammation of the vein can cause pain that may be constant or increase with movement or palpation, indicating irritation or potential damage to the vessel.

E) Erythema: Erythema, or redness at the IV site, is a hallmark sign of phlebitis. The inflammation results in redness around the insertion area, which may spread along the vein, further indicating the presence of irritation or infection at the site.

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Correct Answer is A

Explanation

A. "He has so many new bruises on his body."

This statement raises concerns about potential adverse effects of carbamazepine, such as hematologic effects like thrombocytopenia, which could manifest as bruising. Given the potential seriousness of this issue, it should be the nurse's priority to further assess and address.

B. "He says his mouth is always dry."

Dry mouth (xerostomia) is a common side effect of carbamazepine, but it is generally not as concerning as other potential adverse effects such as hematologic issues or liver toxicity.

C. "He says he feels sick to his stomach after taking this medication."

Gastrointestinal side effects, including nausea, are common with carbamazepine but are typically not as urgent or serious as other potential adverse effects.

D. "He takes a 2-hour nap every day after school."

While changes in sleep patterns can be important to monitor, especially in adolescents, it is not as urgent as addressing potential adverse effects such as bruising.

A. Dystonia B. Tardive dyskinesia C. Parkinsonism D. Akathisia

Correct Answer is B

Explanation

A. Dystonia - Dystonia presents as sustained or intermittent muscle contractions causing abnormal, often repetitive, movements or postures. It is an acute extrapyramidal side effect of antipsychotic medications like chlorpromazine but typically manifests as sudden-onset muscle spasms rather than involuntary movements of the tongue and face.

B. Tardive dyskinesia - Tardive dyskinesia is a late-appearing movement disorder characterized by involuntary, repetitive movements of the face, tongue, and limbs. It is associated with long-term use of antipsychotic medications like chlorpromazine and typically develops after months to years of treatment.

C. Parkinsonism - Parkinsonism resembles Parkinson's disease and is characterized by symptoms such as tremor, rigidity, bradykinesia, and postural instability. While antipsychotic medications can cause Parkinsonism as an adverse effect, it usually presents with symptoms different from those described in the scenario.

D. Akathisia - Akathisia is characterized by an inner feeling of restlessness and the urge to move, often accompanied by pacing and inability to sit still. It is an acute extrapyramidal side effect of antipsychotic medications but does not manifest as involuntary movements of the tongue and face as described in the scenario.

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A nurse is assessing a client who has a peripheral IV with a continuous infusion. Which of the following findings is a manifestation of phlebitis? (Select all that apply)(Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the client's parent is the nurse's priority?

Correct Answer is A

Explanation

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?

Correct Answer is B

Explanation

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