A nurse is reinforcing teaching with the parent of a child who has otitis media and a new prescription for amoxicillin oral suspension. Which of the following information should the nurse include?
This medication can cause ringing in the ears.
This medication can cause muscle pain.
This medication can cause loose stools.
This medication can cause blurred vision.
The Correct Answer is C
Choice A rationale:
This medication can cause ringing in the ears (Choice A) is not a common side effect of amoxicillin. Ringing in the ears (tinnitus) is not typically associated with the use of this antibiotic.
Choice B rationale:
This medication can cause muscle pain (Choice B) is not a common side effect of amoxicillin. Muscle pain is not among the usual adverse reactions associated with its use.
Choice C rationale:
This medication can cause loose stools (Choice C) is a relevant side effect of amoxicillin. Antibiotics, including amoxicillin, can disrupt the normal balance of gut bacteria, potentially leading to gastrointestinal disturbances such as diarrhea or loose stools.
Choice D rationale:
This medication can cause blurred vision (Choice D) is not a common side effect of amoxicillin. Blurred vision is not a typical adverse effect associated with the use of this antibiotic.
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Correct Answer is ["A"]
Explanation
It is essential for the nurse to stay with the client in this situation. The client's presentation indicates manic behavior, which can be associated with bipolar disorder. Manic episodes can lead to increased energy levels, decreased need for sleep, agitation, and impulsivity. The client's refusal to sit down, pacing, and becoming agitated when asked questions all indicate potential risk to themselves or others. Staying with the client ensures their safety and the safety of others in the environment. The nurse can provide verbal support, prevent potential harm, and de-escalate the situation if needed.
Placing the client in a room close to the nurses' station might be helpful for monitoring and quick assistance, but it doesn't directly address the client's immediate agitation and need for supervision. The priority in this scenario is to ensure the client's safety, which can be achieved by staying with them.
Offering the client a caffeinated beverage is not appropriate in this situation. Caffeine can exacerbate agitation and restlessness, potentially worsening the client's symptoms. It's important to provide a calm and supportive environment instead.
Weighing the client daily is not relevant to the current situation. The client's agitation and need for supervision take precedence over routine assessments like daily weight measurement.
Offering the client finger foods is also not appropriate in this situation. The client's behavior and presentation suggest a manic episode, and their agitation indicates that they are not in a state to engage in eating. Ensuring safety and providing emotional support are the immediate priorities.
Correct Answer is A
Explanation
Choice A rationale:
Swelling around the eyelids and mouth could indicate an allergic reaction, which can be severe in some cases. Anaphylaxis is a life-threatening reaction that can occur after immunizations. The nurse's priority is to assess and address any signs of an allergic reaction promptly. Swelling of the face, particularly around the eyes and mouth, is a red flag for potential anaphylaxis, and immediate intervention is necessary to prevent further complications.
Choice B rationale:
A temperature of 100.7 degrees Fahrenheit is considered a mild fever. While it's important to monitor for fever after immunizations, a mild fever alone may not be the nurse's top priority, especially if the child is otherwise stable. Fever can be a common post-immunization response and is often self-limiting.
Choice C rationale:
While monitoring the child's intake is important, only eating 2 ounces during the last feeding is not a priority concern compared to potential allergic reactions or fever. A temporary decrease in appetite following immunizations can be expected and might resolve on its own.
Choice D rationale:
Crying when the injection site is touched is a common response to discomfort from the shot. While it's essential to provide comfort and support to the child, this finding is not indicative of a severe reaction. It's not the nurse's priority compared to potential signs of an allergic reaction or a more significant fever.
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