Exhibits
The nurse is evaluating the client's progress and nursing implementations.
Click to highlight the findings that would indicate the client has recovered from the adverse drug reaction.
1230:
Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored. Drowsy.
Shaking is lessened
Client is no longer flushed
No longer itching
Anxiety has decreased
Skin warm and dry
Heart rate 62 beats/minute, blood pressure 130/72 mm Hg
No chest pain noted
Respirations are even and unlabored
Drowsy
The Correct Answer is ["A","B","C","D","E","F","G","H","I"]
- Shaking is lessened: Shaking or tremors can be a manifestation of the body's response to stress or discomfort. A decrease in shaking suggests that the client's physiological response is returning to normal, indicating improvement.
- Client is no longer flushed: Flushing, or the reddening of the skin, can occur as a result of vasodilation during an allergic reaction or due to increased blood flow associated with elevated body temperature. The absence of flushing suggests that the body's inflammatory response has subsided, indicating resolution of the adverse reaction.
- No longer itching: Itching, or pruritus, is a common symptom of allergic reactions mediated by histamine release. The cessation of itching suggests that the inflammatory mediators responsible for the itching response have been cleared from the body, indicating resolution of the allergic reaction.
- Anxiety has decreased: Anxiety can be a psychological response to physical discomfort or distress. A decrease in anxiety levels suggests that the client is experiencing less discomfort and is psychologically improving, which can be indicative of recovery from the adverse drug reaction.
- Skin warm and dry: Warm and dry skin is a sign of normal thermoregulation and hydration status. The presence of warm and dry skin suggests that the client's body temperature and hydration levels are within normal limits, indicating physiological stability and recovery from the adverse drug reaction.
- Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: Vital signs within normal limits, including a heart rate and blood pressure within the client's baseline range, indicate stability of cardiovascular function and resolution of any hemodynamic instability associated with the adverse drug reaction.
- No chest pain noted: Chest pain can be indicative of cardiovascular compromise or ischemia. The absence of chest pain suggests that the client's cardiovascular function has normalized, further supporting recovery from the adverse drug reaction.
- Respirations are even and unlabored: Even and unlabored respirations indicate normal respiratory function and adequate gas exchange. The absence of respiratory distress or effort suggests resolution of any respiratory complications associated with the adverse drug reaction.
- Drowsy: Drowsiness can be a side effect of medications such as antihistamines or a natural response to the body's recovery process. While drowsiness may persist for a period after the adverse drug reaction resolves, its presence alongside other signs of improvement suggests that the client's body is returning to a state of equilibrium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A,B,C"},"B":{"answers":"A,B"},"C":{"answers":"B"},"D":{"answers":"B,C"},"E":{"answers":"A,B,C"}}
Explanation
- Decreased hemoglobin and hematocrit levels: Consistent with iron deficiency anemia, vitamin B12 deficient anemia, and folic acid deficient anemia. Iron deficiency anemia results from
inadequate iron stores, while vitamin B12 deficient anemia and folic acid deficient anemia are characterized by inadequate levels of these respective vitamins, all of which contribute to decreased hemoglobin and hematocrit levels.
- Uptake often impeded by medications: Consistent with iron deficiency anemia and vitamin B12 deficient anemia. Iron absorption can be affected by certain medications, such as proton pump
inhibitors or antacids, which can hinder iron uptake. Vitamin B12 deficiency can result from medications that interfere with its absorption, such as proton pump inhibitors or metformin.
- Often associated with chronic alcoholism: Consistent with vitamin B12 deficient anemia. Chronic alcoholism can lead to vitamin B12 deficiency due to poor dietary intake,
malabsorption, or liver dysfunction associated with excessive alcohol consumption.
- Can be caused by malabsorption syndrome: Consistent with vitamin B12 deficient anemia and folic acid deficient anemia. Malabsorption syndromes, such as celiac disease or Crohn's disease, can impair the absorption of both vitamin B12 and folic acid from the gastrointestinal tract,
leading to deficiencies.
- Result of dietary deficiency: Consistent with iron deficiency anemia, vitamin B12 deficient anemia, and folic acid deficient anemia. Iron deficiency anemia results from inadequate dietary intake of iron-rich foods, while vitamin B12 deficient anemia and folic acid deficient anemia stem from insufficient dietary intake of foods rich in these respective vitamins.
Correct Answer is C
Explanation
A. Maintaining nasal packing may be important post-hypophysectomy to prevent bleeding or cerebrospinal fluid leaks. However, in the context of Cushing's disease, ensuring oral hygiene is
paramount due to increased risk of infection, especially if the patient is on corticosteroid therapy, which suppresses the immune system.
B. Keeping the head of the bed at 30° helps prevent complications such as cerebral edema and increased intracranial pressure. While this is important post-hypophysectomy, it's not specific to Cushing's disease or a priority over oral care.
C. Providing frequent mouth care is crucial in Cushing's disease due to increased cortisol levels leading to immunosuppression and susceptibility to infections. Additionally, glucocorticoid therapy can cause mucosal dryness and ulceration, necessitating meticulous oral hygiene.
D. Monitoring intake and output is essential postoperatively to assess fluid balance and renal function. While important, it's not the priority in this context compared to oral care, especially considering the risk of dehydration due to increased cortisol levels in Cushing's disease.
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