A nurse is providing care to a group of patients with chronic illnesses.

Who among the following patients should the nurse identify as being at the highest risk for sepsis?

Choice A rationale

Lidocaine does not primarily serve to relieve pain when administered intravenously. It is primarily used as an antiarrhythmic agent.

Choice B rationale

Lidocaine does not slow intestinal motility. This is not one of its primary actions.

Choice C rationale

Lidocaine does not dissolve blood clots. It is not an anticoagulant.

Choice D rationale

Lidocaine prevents dysrhythmias. It is an antidysrhythmic medication that delays the conduction in the heart and reduces the automaticity of heart tissue.

Choice A rationale: CNS manifestations such as headaches are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin, a gonadotropin-releasing hormone (GnRH) agonist, works by reducing the production of estrogen in the body. This can lead to a variety of side effects, including headaches. While these side effects can be bothersome, they do not indicate that the medication is effectively treating the endometriosis.

Choice B rationale: The reduction in pain level during sexual intercourse, or dyspareunia, is a therapeutic effect of nafarelin. Endometriosis can cause painful sexual intercourse, and one of the goals of treatment with nafarelin is to reduce this pain. The client’s report of decreased dyspareunia suggests that the nafarelin is effectively treating the endometriosis.

Choice C rationale: Changes in the nasal mucosa, such as irritation, are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin is administered intranasally, which can lead to irritation of the nasal mucosa. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.

Choice D rationale: Changes in breast size are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin can cause a variety of side effects, including changes in breast size. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.

Choice E rationale: The absence of menstruation, or amenorrhea, is a therapeutic effect of nafarelin. Nafarelin works by reducing the production of estrogen in the body, which can lead to a temporary halt in menstruation. This is a therapeutic effect as it can help to reduce the pain and other symptoms associated with endometriosis.

Choice F rationale: Dermatological manifestations such as increased acne are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin can cause a variety of side effects, including increased acne. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.