An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

A coronary artery bypass procedure was performed in 1995.

Suﬀered with depression following death of spouse in 1999.

Digoxin and furosemide daily since 1996.

A Colonoscopy was performed for routine screening six months ago.

Answer and Explanation

The Correct Answer is C

Digoxin is a medication commonly used to treat heart failure by strengthening the heart's contractions and slowing down the heart rate. However, it can also cause nausea, vomiting, and loss of appetite, especially when levels in the body are too high. Furosemide is a diuretic medication that helps to remove excess ﬂuid from the body, which is often necessary in heart failure. However, it can also cause electrolyte imbalances, such as low potassium levels, which can contribute to nausea and vomiting.

Therefore, in a client with heart failure who is experiencing these symptoms, it is important to assess their medication regimen, including dosages and serum levels, to ensure that they are not experiencing medication side eﬀects or toxicity.

Adjustments may need to be made to the client's medication regimen to manage symptoms eﬀectively and prevent further complications. Options (a), (b), and (d) do not have as direct a correlation to the current symptoms and would not have the same level of significance when planning care for this client.

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Correct Answer is C

Explanation

Diabetes insipidus is a condition in which the kidneys are unable to conserve water, leading to excessive thirst and urination. It is treated with antidiuretic hormone (ADH), which helps the kidneys retain water and reduce urine output. When caring for a client with diabetes insipidus who is receiving ADH intranasally, it is important for the nurse to monitor the client’s serum osmolality.

Osmolality is a measure of the concentration of particles in a solution and can provide information about the client’s hydration status.

Monitoring serum osmolality can help determine if the ADH therapy is eﬀective in managing the client’s diabetes insipidus.

A. Obtain an extra pillow for the client to use at night. B. Provide the client with a heating pad to place around the neck. C. Give PRN prescription for benztropine. D. Obtain a prescription for physical therapy services.

Correct Answer is C

Explanation

Continuous rubbing of the back of the neck can be a side eﬀect of antipsychotic medication, known as acute dystonia. Benztropine is an anticholinergic medication that can eﬀectively treat acute dystonia. Therefore, the nurse should give a PRN prescription for benztropine to relieve the client's discomfort. Options a, b, and d do not address the underlying issue of acute dystonia and are not the best interventions for this particular situation.

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An elderly client with heart failure comet to the emergency room because of nausea, vomiting, and anorexia. Based on the client’s signs and symptoms, which data from the medical history has the most significance when planning this client’s care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client with diabetes insipidus who is receiving antidiuretic hormone intranasally, which serum lab test is most important for the nurse to monitor?

Correct Answer is C

Explanation

A client with psychosis who is receiving an antipsychotic medication is continuously rubbing the back of the neck. Which nursing intervention is best for the nurse to implement?

Correct Answer is C

Explanation

On admission, the healthcare provider describes a broad spectrum of antibiotic, ticarcillin for a client with a gram-negative infection. Before administering the first dose, it is most important for the nurse to implement which prescription?

The nurse is planning care for a patient with major depression who is receiving a new prescription for duloxetine. Which information is most important for the nurse to obtain?

A client with muscle spasticity receives a prescription for baclofen. Which information provided by the client requires additional instruction by the nurse?

A female client starts a new prescription, oxybutynin, for symptoms of an overactive bladder. The client tells the nurse that she is training to run in a marathon. Which instruction should the nurse emphasize?

Which assessment data indicated to the nurse that a client is having an anaphylactic reaction to a medication?

Before administering a newly prescribed dose of terbinafine HCL to a client with a fungal toenail infection, which assessment finding is most important for the nurse to address?

The nurse is planning to discharge teaching for a client with diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse include in the discharge teaching?