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?

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

"He says his mouth is always dry."

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

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

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is B

Explanation

A. Insert the needle slowly and gently.

This statement is generally true for most injection techniques, including the Z-track method. Slow and gentle insertion helps minimize discomfort for the client and allows for better control over the needle's placement. However, the specific speed of insertion may vary depending on the nurse's technique and the client's skin condition.

B. Pull the skin 1.3 cm (1/2 inch) to the side.

This statement is correct. The Z-track technique involves pulling the skin laterally (to the side) by approximately 1.3 cm (1/2 inch) before inserting the needle. This lateral displacement of the skin creates a zigzag pathway for the medication, which helps prevent leakage or tracking of the medication along the injection site.

C. Aspirate for 5 to 10 seconds.

Aspiration, or pulling back on the plunger of the syringe after needle insertion, is not typically recommended for intramuscular injections, including those using the Z-track method. Aspiration may increase the risk of tissue trauma or damage to blood vessels. Since the Z-track technique is designed to minimize medication leakage into the subcutaneous tissue, aspiration is usually unnecessary.

D. Use a 45° angle of insertion.

The angle of insertion for the Z-track technique is typically 90 degrees (perpendicular) to the skin surface rather than 45 degrees. This angle allows for proper depth penetration into the muscle and ensures adequate delivery of the medication into the muscle tissue.

Correct Answer is ["2"]

Explanation

To calculate the volume of chlorpromazine to administer per dose, we'll use the formula:

Volume(mL)=Totaldoseneeded(mg)/Concentrationofthemedication(mg/mL)

Given: Total dose needed per dose = 50 mg

Concentration of chlorpromazine injection = 25 mg/mL

Substituting the given values into the formula:

Volume(mL)=50 mg/25 mg/mL

Volume(mL)=2 mL

Rounded to the nearest whole number, the nurse should administer 2 mL of chlorpromazine per dose.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to use the Z-track technique to administer a medication to a client. Which of the following is an appropriate action during this procedure?

Correct Answer is B

Explanation

Correct Answer is ["2"]

Explanation

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