A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol.
For which of the following adverse effects should the nurse monitor?
Headache.
Hypertension.
Tinnitus.
Insomnia.
The Correct Answer is C
Choice A rationale:
Headache is a common adverse effect of disulfiram when alcohol is consumed. It is part of the adverse reaction created by the drug to deter individuals from drinking. While headache is a known symptom, tinnitus is a more specific and distinctive adverse effect associated with disulfiram use.
Choice B rationale:
Hypertension is not a common adverse effect of disulfiram. Disulfiram does not directly impact blood pressure. Its primary action is to cause an adverse reaction when alcohol is consumed.
Choice C rationale:
Tinnitus (ringing in the ears) is a known adverse effect of disulfiram when alcohol is ingested. Disulfiram inhibits the breakdown of acetaldehyde, leading to an accumulation of this toxic substance in the body. Tinnitus is one of the symptoms of this toxic reaction and is a significant concern in individuals taking disulfiram for alcohol use disorder.
Choice D rationale:
Insomnia is not a common adverse effect of disulfiram. Disulfiram works by creating an unpleasant reaction when alcohol is consumed, which deters individuals from drinking. This reaction does not typically manifest as insomnia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To calculate how many tablets of levothyroxine the nurse should administer, we'll need to convert the dose to the same unit as the available tablets. Here's the step-by-step process:
Convert the desired dose to milligrams (mg): 50 micrograms (mcg) = 50 / 1000 mg (since 1 mg = 1000 mcg) 50 mcg = 0.05 mg
Now, find out how many tablets of 0.025 mg each are required to achieve the desired dose: Number of tablets = Desired dose (in mg) / Tablet strength (in mg) Number of tablets = 0.05 mg / 0.025 mg Number of tablets = 2 tablets
Therefore, the nurse should administer 2 tablets per dose.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale:
Transferring a client to physical therapy is a task that can be safely delegated to an assistive personnel (AP) as long as the client does not have any specific medical restrictions or requires specialized assistance during the transfer. APs are trained to assist with activities of daily living, including transferring clients from one place to another. However, it is essential for the nurse to assess the client's condition and provide clear instructions to the AP to ensure a safe transfer.
Choice B rationale:
Obtaining a client's vital signs every 4 hours is a routine task that can be delegated to an assistive personnel. APs are trained to measure vital signs such as blood pressure, heart rate, respiratory rate, and temperature under the supervision of licensed healthcare providers. Regular monitoring of vital signs is crucial in assessing the client's overall health status and detecting any changes that might require immediate medical attention.
Choice E rationale:
Recording a client's intake after each meal is a task that can be delegated to an assistive personnel. APs can document the amount and type of food and fluids consumed by the client. Monitoring the client's intake is important, especially if the client has specific dietary restrictions, allergies, or medical conditions that require close monitoring of their food and fluid intake.
Choice C rationale:
Instructing a client on the use of an incentive spirometer requires specialized knowledge and assessment of the client's respiratory status. This task should be performed by a licensed healthcare provider, such as a nurse or respiratory therapist, who can properly assess the client's lung function, demonstrate the correct technique, and ensure the client's safety during the process. Delegating this task to an AP could result in improper use of the spirometer, potentially leading to complications or ineffective therapy.
Choice D rationale:
Inserting an NG tube for a client who requires enteral feedings is a complex medical procedure that should be performed by a licensed nurse or healthcare provider with appropriate training and expertise. This procedure carries risks, including the risk of aspiration if not done correctly. Delegating this task to an AP is outside their scope of practice and could jeopardize the client's safety.
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