A nurse is reviewing the vital signs of a client who has a prescription for imipramine. Which of the following findings requires follow-up by the nurse?
Temperature 36.7° C (98° F)
Respiratory rate 16/min
Blood pressure 88/64 mm Hg
Pulse rate 66/min
The Correct Answer is C
A. Temperature 36.7° C (98° F): This temperature is within normal limits for an adult and does not indicate a complication related to imipramine use. No immediate intervention is needed based on this finding.
B. Respiratory rate 16/min: A respiratory rate of 16 breaths per minute is within the normal adult range (12–20/min) and does not raise concern for adverse effects from imipramine. It requires routine monitoring only.
C. Blood pressure 88/64 mm Hg: Imipramine, a tricyclic antidepressant, can cause orthostatic hypotension and other hypotensive effects. A blood pressure of 88/64 mm Hg is lower than normal and may indicate drug-induced hypotension, which requires follow-up, monitoring for symptoms such as dizziness or syncope, and possibly notifying the prescriber.
D. Pulse rate 66/min: A pulse rate of 66 beats per minute is within the normal adult range (60–100 bpm) and does not indicate a cardiovascular complication related to imipramine. Routine monitoring is sufficient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It can take several weeks before you notice an effect from the medication.": Buspirone is an anxiolytic that requires consistent daily dosing, and its therapeutic effects may take 2–4 weeks to become noticeable. Educating the client about this delayed onset helps set realistic expectations and promotes adherence to the medication regimen.
B. "If a dose is missed, you can take the missed dose along with the next scheduled dose.": Doubling doses to make up for a missed dose can increase the risk of adverse effects and is not recommended. Clients should be instructed to skip the missed dose and resume the normal dosing schedule.
C. "Avoid consuming large amounts of leafy, green vegetables while taking this medication.": There are no dietary restrictions regarding leafy greens or vitamin K with buspirone. This instruction is unnecessary and unrelated to the medication’s pharmacology.
D. "This medication is known to cause dependence.": Unlike benzodiazepines, buspirone has a low potential for dependence or abuse. It is considered safe for long-term use in managing generalized anxiety disorder without significant risk of addiction.
Correct Answer is ["B","D","E","F"]
Explanation
Rationale for correct choices
• Client has identified several coping mechanisms when they feel tempted to use the substances: Developing coping strategies is a key indicator of progress in substance use disorder treatment. It shows the client is gaining insight into triggers and is preparing practical approaches to manage cravings, reducing the likelihood of relapse.
• Client states that they have a plan to receive their methadone daily following discharge: Adherence to medication-assisted therapy like methadone demonstrates the client is engaging in ongoing treatment, which supports sustained recovery and helps prevent withdrawal symptoms or relapse.
• The client has written a plan for what to do if relapse should occur: Creating a relapse prevention plan reflects proactive problem-solving and understanding of recovery challenges. It indicates the client is taking responsibility for their own care and preparing for potential setbacks, which is expected progress.
• Client states that they are willing to participate in outpatient therapy following discharge: Willingness to continue therapy after discharge demonstrates commitment to long-term recovery. Engagement in structured follow-up is a positive outcome and reflects the client’s motivation to maintain sobriety.
Rationale for Incorrect choices
• Client denies that substance use was triggered by any childhood trauma: While the client’s perception is noted, this statement does not directly reflect progress in coping, treatment adherence, or relapse prevention. It is informational but does not indicate measurable advancement in recovery goals.
• Client states that they are looking forward to seeing old friends when they are released from the hospital: Anticipating contact with old friends may pose a risk of relapse if these friends are associated with substance use. This statement may indicate potential triggers rather than expected improvement.
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