After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Serum potassium and skin turgor.

Eosinophil count and constipation.

Blood pressure and risk for falls.

Heart rate and reports of nausea.

Answer and Explanation

The Correct Answer is C

Choice A reason: Monitoring serum potassium is relevant, as lisinopril can cause hyperkalemia by reducing aldosterone, impairing potassium excretion. Skin turgor, however, assesses hydration, not ACE inhibitor effects. Blood pressure monitoring is more critical, as lisinopril lowers blood pressure via vasodilation, risking hypotension and falls, especially in elderly clients.

Choice B reason: Eosinophil count and constipation are unrelated to lisinopril’s effects. Elevated eosinophils may suggest allergies, but this is rare with ACE inhibitors. Constipation is not a common side effect. Lisinopril’s primary action is renin-angiotensin inhibition, making blood pressure and fall risk monitoring more urgent to prevent hypotensive complications.

Choice C reason: Lisinopril reduces angiotensin II, promoting vasodilation and lowering blood pressure. Monitoring blood pressure detects hypotension, which increases fall risk, particularly in older adults, due to dizziness or orthostatic changes. This directly assesses the drug’s cardiovascular effects, ensuring safety by preventing falls or syncope, making it the priority assessment.

Choice D reason: Heart rate and nausea are not primary lisinopril concerns. Tachycardia may occur secondary to hypotension, and nausea is rare. The drug’s main effect is blood pressure reduction via ACE inhibition, necessitating monitoring for hypotension and fall risk to ensure patient safety, as these are more immediate and significant pharmacological effects.

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Correct Answer is A

Explanation

Choice A reason: Increased JVD and pedal edema indicate fluid overload in heart failure, where reduced cardiac output causes venous congestion. Assessing breathing for dyspnea or crackles detects pulmonary edema, as fluid backs into alveoli, impairing gas exchange. This urgent finding guides interventions like diuretics, critical before reporting.

Choice B reason: Palpating pedal pulses assesses arterial flow, not fluid overload causing JVD and edema, which are venous issues in heart failure. Pulses may be normal despite congestion. Breathing changes indicate pulmonary edema, a life-threatening complication, making this assessment more critical for detecting acute decompensation.

Choice C reason: Assessing calf inflammation may detect thrombosis, a heart failure risk, but JVD and edema suggest fluid overload, not clotting. Breathing changes are more urgent, indicating pulmonary edema from alveolar fluid, requiring immediate intervention to prevent respiratory failure, unlike inflammation, which is less immediate.

Choice D reason: Inspecting peripheral vein distention confirms venous congestion but is less critical than breathing assessment. In heart failure, fluid overload risks pulmonary edema, where alveolar fluid causes dyspnea. Monitoring breathing detects this severe complication, prioritizing intervention to ensure oxygenation over additional venous assessment.

A. Discuss checking the time frequently. B. Ask the client why she checks the locks. C. Plan a list of activities to be carried out daily. D. Determine the type and size of the locks.

Correct Answer is C

Explanation

Choice A reason: Discussing time-checking does not address compulsive lock-checking, likely obsessive-compulsive disorder (OCD), driven by serotonin dysregulation causing intrusive fears. Time management is unrelated to compulsions. Planning activities reduces idle time, distracting from OCD behaviors, addressing the neurobiological basis more effectively.

Choice B reason: Asking why the client checks locks may heighten anxiety in OCD, as compulsions arise from irrational fears, not logic, via cortico-striatal-thalamic dysfunction. This may reinforce obsessions. Activity planning distracts from compulsions, offering a therapeutic approach to improve function, making questioning less effective.

Choice C reason: Planning daily activities structures time, reducing compulsive lock-checking in OCD, where obsessive fears disrupt function. Engaging tasks modulate serotonin, distracting from cortico-striatal overactivity, improving behavioral control. This addresses the disorder’s impact, enhancing functionality by minimizing compulsion opportunities, making it the best action.

Choice D reason: Determining lock type is irrelevant to OCD’s compulsive checking, rooted in neurobiological fear responses, not lock characteristics. This does not address serotonin imbalance. Activity planning redirects focus to structured tasks, reducing compulsions, making lock assessment ineffective for managing the client’s behavior.

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After administering lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, it is most important for the nurse to monitor which assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with heart failure is receiving intravenous fluids at 125 mL/hour. The nurse observes an increase in jugular vein distention (JVD) and pedal edema. Which additional assessment should the nurse make before reporting to the healthcare provider?

Correct Answer is A

Explanation

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Correct Answer is C

Explanation

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