A nurse is making a follow-up call to client who has a new prescription for ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?
*Restrict your daily fluid intake."
*Take a daily potassium supplement."
*Discontinue this medication if this occurs again."
"Sit back down for a few minutes when this occurs."
The Correct Answer is D
A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.
B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.
C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.
D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) I’d like to hear your thoughts about giving yourself this medication:
This response encourages open communication and allows the client to express their concerns or fears. It shows empathy and provides an opportunity for the nurse to understand the reasons behind the refusal, which can help tailor the teaching approach. This is an effective way to build trust and involve the client in their care plan.
B) Have you considered how your decision to refuse medication will affect your family?
While this statement highlights the consequences of the client’s actions, it can feel judgmental or guilt-inducing, which may cause the client to become defensive. The nurse should aim to engage the client in a non-judgmental and supportive way rather than focusing on external consequences at this stage.
C) Why don’t you want to learn how to give yourself your medication?
This question could come across as confrontational and may make the client feel pressured or defensive. Instead of focusing directly on the refusal, the nurse should try to understand the client's perspective and barriers, which can be better achieved with a more open and empathetic approach like option A.
D) You will suffer serious health issues if you don’t take your medication:
This response may evoke fear and could be perceived as coercive. It focuses on the negative consequences without first understanding the client’s feelings or reasons for refusing. While the nurse should eventually address the importance of insulin, it’s more effective to first create an open dialogue that respects the client’s autonomy and concerns.
Correct Answer is B
Explanation
A) Encourage the family to be with the child during mealtimes: While family support during mealtimes can be helpful, it is not the first priority in this situation. The most important step is to understand the child’s dietary habits and challenges in order to create a more targeted and effective approach to addressing the poor dietary intake.
B) Obtain the child’s dietary history: The first step should be to gather information about the child’s dietary history. Understanding what the child is eating, how often, and any potential barriers to proper nutrition (e.g., food preferences, allergies, or cultural practices) is crucial for identifying the root cause of the poor dietary intake. This information will guide the nurse in making appropriate recommendations for improving the child's nutrition.
C) Instruct the family to praise the child when they eat: While positive reinforcement can be a useful strategy, it is not the first step in addressing poor dietary intake. The nurse needs to assess the child’s dietary habits and any possible issues before recommending specific behavioral strategies.
D) Offer the child nutritious snacks between meals: Offering nutritious snacks is a good strategy for improving a child’s nutrition, but it should come after gathering a clear understanding of the child’s eating habits. Without knowing the child’s preferences and needs, it’s better to first assess and identify the cause of the poor intake before recommending snacks.
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