A nurse is caring for a client who consumed alcohol 2 days after taking disulfiram. The nurse should monitor the client for which of the following findings?
Constipation
Dry skin
Hypotension
Urinary retention
The Correct Answer is C
Choice A reason: Constipation isn’t a primary effect of disulfiram-alcohol reaction, which causes acetaldehyde buildup, triggering vasodilation and nausea, not gut motility issues. Scientifically, this reaction targets cardiovascular and systemic responses, lacking evidence for significant gastrointestinal stasis as a monitored outcome in this scenario.
Choice B reason: Dry skin isn’t linked to disulfiram-alcohol interaction, which induces flushing and sweating from acetaldehyde toxicity, not dehydration. Scientifically, the reaction affects vascular and autonomic systems, producing moist, not dry, skin responses, making this an unrelated finding for monitoring here.
Choice C reason: Hypotension occurs in disulfiram-alcohol reaction as acetaldehyde dilates vessels, dropping blood pressure. This cardiovascular effect, alongside tachycardia, is a key sign to monitor, aligning with scientific understanding of the drug’s inhibition of aldehyde dehydrogenase, causing systemic distress.
Choice D reason: Urinary retention isn’t a typical disulfiram-alcohol effect; the reaction focuses on vasodilation, nausea, and hypotension from acetaldehyde. Scientifically, autonomic overstimulation may occur, but bladder dysfunction isn’t a primary outcome, making this less critical to monitor than cardiovascular collapse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Persistent contractions signal labor or abruption, not previa. Placenta previa causes painless bleeding from placental positioning, not uterine activity.
Choice B reason: Increased fetal movement isn’t tied to previa; it’s a fetal response indicator. Previa’s hallmark is maternal bleeding, not fetal behavior changes.
Choice C reason: Rigid abdomen suggests abruption with clot formation, not previa. Previa bleeding is external, leaving the uterus soft, not tense.
Choice D reason: Bright red vaginal bleeding is classic in placenta previa, from low placental implantation. It’s painless, distinguishing it from other complications.
Correct Answer is B
Explanation
Choice A reason: A 90-degree angle is too upright; newborns need a 30-45-degree recline to protect airways. This shows misunderstanding of safe positioning.
Choice B reason: Rear-facing until age 2 supports neck and spine safety, per guidelines. This reflects correct understanding of car seat standards for newborns.
Choice C reason: Retainer clips belong at chest level, not belly, for harness safety. This indicates incorrect knowledge of car seat strap placement.
Choice D reason: Airbags endanger front-seat infants; rear seating is mandatory. Enabling them shows a dangerous misunderstanding of car seat safety protocols.
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