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 D

Explanation

The client is experiencing syncope (fainting) due to a drop in blood pressure to 70/40 mm Hg, which is too low. This suggests that the client's blood pressure medications are reducing their blood pressure too much, resulting in hypotension. The rationale for the nurse's decision to hold the client's scheduled antihypertensive medications is to prevent further hypotension and allow the client's blood pressure to stabilize at a safer level.

Option a is incorrect because diuresis (increased urine output) is not a likely cause of the client's hypotension.

Option b is incorrect because the client's symptoms suggest hypotension due to reduced blood pressure, rather than drug toxicity.

Option c is incorrect because the antagonistic interaction among blood pressure medications would result in reduced eﬀectiveness but would not necessarily cause hypotension.

A. Use stool softener as needed. B. Avoid ingestion of alcohol. C. Discontinue when spasms cease. D. Take medication with meals.

Correct Answer is C

Explanation

Baclofen is a muscle relaxant medication used to treat muscle spasticity, which is a condition that causes muscles to become stiﬀ and rigid. It works by reducing the activity of nerves in the brain and spinal cord that cause muscle spasms.

Option a, using stool softener as needed, is appropriate because baclofen can cause constipation as a side eﬀect.

Option b, avoiding ingestion of alcohol, is also appropriate because alcohol can increase the sedative eﬀects of baclofen and cause drowsiness or dizziness.

Option d, taking medication with meals, is recommended because it can help reduce stomach upset and nausea that may occur as a side eﬀect of the medication.

Option c, discontinuing the medication when spasms cease, is incorrect because muscle spasticity is a chronic condition, and baclofen is used to manage symptoms over a prolonged period. Discontinuing the medication abruptly can cause withdrawal symptoms and exacerbate the spasticity. Therefore, the nurse should educate the client to take the medication as prescribed by the healthcare provider and not discontinue it without medical advice.

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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

A client who receives multiple antihypertensive multiple medications experiences syncope due to a drop in blood pressure to 70/40 mm Hg. Which is the rationale for the nurse’s decision to hold the client’s scheduled antihypertensive medications?

Correct Answer is D

Explanation

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

Correct Answer is C

Explanation

The nurse assesses a client with intermittent claudication who is receiving pentoxifylline. Which assessment should the nurse perform to determine the eﬀectiveness of the medication?

A client with hepatic encephalopathy is receiving lactulose. Which assessment provides the nurse with the nest information to evaluate the client’s therapeutic response to the drug?

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?

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?

A female client with a history of peptic ulcer disease receives a prescription for misoprostol. Which information provided by the client indicates to the nurse a need for further teaching?

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?

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?

Before administering initial dose of sumatriptan succinate to a client with a migraine headache, it is most to determine if the client’s history includes which problem?