A nurse is caring for a client who has heart failure and has started taking a loop diuretic.
Which of the following findings indicates the client is experiencing an adverse effect of the medication?

Decreased reflexes

Weight gain of 1.4 kg (3 lb)

Increased urinary output

Jugular vein distention

Answer and Explanation

The Correct Answer is A

Rationale for A: Decreased reflexes can indicate hypokalemia, an adverse effect of loop diuretics. Loop diuretics increase the excretion of potassium, which can lead to low potassium levels, manifesting as muscle weakness and diminished reflexes.

Rationale for B: Weight gain, especially in the context of heart failure, suggests fluid retention rather than an adverse effect of a loop diuretic, which is expected to reduce fluid retention by promoting diuresis.

Rationale for C: Increased urinary output is an expected effect of loop diuretics, as they are used to remove excess fluid. This would not be considered an adverse effect unless it leads to dehydration or electrolyte imbalances.

Rationale for D: Jugular vein distention indicates fluid overload, which would suggest that the diuretic is not effective or that the heart failure is worsening. It is not a direct adverse effect of the medication itself.

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Correct Answer is D

Explanation

A. Strong contractions are expected with oxytocin augmentation and do not require a decrease in the infusion rate.
B. A cervical dilation rate of 1 cm every 4 hours is slow but does not indicate the need to decrease oxytocin.
C. Contractions lasting 80 seconds are prolonged but do not necessarily indicate hyperstimulation.
D. Contractions occurring every 90 seconds suggest uterine tachysystole, which can compromise fetal oxygenation and requires a decrease in the oxytocin infusion rate.

A. Compulsive attention to details B. Avoids interacting with others C. Uses others for personal gain. D. Socially awkward in group situations

Correct Answer is C

Explanation

A. Compulsive attention to details: This behavior is more characteristic of obsessive-compulsive personality disorder rather than antisocial personality disorder.

B. Avoids interacting with others: Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, but avoidance of social interaction is not a typical

feature.

C. Uses others for personal gain: This behavior aligns with the manipulative and exploitative tendencies often seen in individuals with antisocial personality disorder.

D. Socially awkward in group situations: While individuals with antisocial personality disorder may have difficulty forming meaningful relationships, they often have superficial charm and can be socially adept, so being socially awkward in group situations is less indicative of this disorder.

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A nurse is caring for a client who has heart failure and has started taking a loop diuretic. Which of the following findings indicates the client is experiencing an adverse effect of the medication?

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A nurse is caring for a client who has heart failure and has started taking a loop diuretic.
Which of the following findings indicates the client is experiencing an adverse effect of the medication?