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 A
Explanation
Choice A reason: Injecting 15 units of air into regular insulin balances vial pressure, per protocol. This step precedes drawing regular insulin, ensuring accurate mixing sequence.
Choice B reason: Withdrawing NPH now skips regular insulin prep, risking contamination or error. Air injection into both vials comes first in standard insulin administration.
Choice C reason: Verification is key but follows insulin preparation. Air injection sequence precedes dosage checks, making this premature before completing vial prep steps.
Choice D reason: Capping the needle halts the process prematurely. Air must be injected into both vials first to maintain sterile technique and accurate dosing.
Correct Answer is D
Explanation
Choice A reason: Dry mucous membranes signal dehydration, not hyperkalemia directly. High potassium affects cardiac and nerve function, not mucosal hydration status in renal failure.
Choice B reason: Hyperactive reflexes occur in hypocalcemia, not hyperkalemia. Excess potassium depresses nerve and muscle activity, often reducing reflexes instead of enhancing them.
Choice C reason: Trousseau’s sign indicates hypocalcemia, with carpal spasm from cuff pressure. Hyperkalemia in renal failure doesn’t trigger this; it’s a calcium issue.
Choice D reason: Irregular heart rate, like bradycardia or arrhythmias, stems from hyperkalemia’s effect on cardiac conduction. In renal failure, potassium excess disrupts rhythms critically.
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