Mr. Edward Long is a 50-year-old office worker who has gained 50 pounds over the past 5 years. His blood pressure has consistently been high, but he has declined to take medication for the condition. His cholesterol level has been above 210 mg/dL on his last three office visits. He claims to have no chronic diseases and is at the office seeking assistance concerning his weight gain. While there, the healthcare provider speaks to him about his cholesterol level and hypertension.
The health provider ordered atorvastatin (Lipitor) for his high lipids, and hydrochlorothiazide for his hypertension. Mr. Long agrees with this treatment plan. He is returning now for a 1 month follow-up.Which of the following assessment findings is a priority for the nurse to follow- up?
Blood pressure 130/80
States knee pain is currently a 5/10 (on a 0 to 10 pain intensity scale)
Hypoactive bowel sounds X4
Complains of muscle weakness
The Correct Answer is D
Explanation:
A. A blood pressure of 130/80 is within the target range (below 140/90 for most individuals) and does not require immediate follow-up.
B. Knee pain, while important, is not an immediate priority compared to potential medication side effects or complications.
C. Hypoactive bowel sounds, while needing monitoring, are not typically a priority over potential adverse effects of medication.
D. Complaints of muscle weakness could indicate a potential side effect of atorvastatin (Lipitor), which should be promptly addressed to prevent complications such as rhabdomyolysis. Therefore, it is the priority assessment finding for the nurse to follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Explanation:
A. Headache is a common side effect of nitroglycerin due to vasodilation and can often be managed with continued use.
B. Nitroglycerin is known to cause headaches as a common side effect.
C. Taking nitroglycerin with a high-fat meal is not likely to prevent headaches; it may, in fact, delay absorption and onset of action.
D. A headache alone is not indicative of a serious allergic reaction to nitroglycerin; other symptoms would typically be present.
Correct Answer is D
Explanation
Explanation:
A. Discussing how food can increase the symptoms of depression is not the priority in this situation; the immediate concern is the interaction between phenelzine and wine.
B. Admitting the client to the psychiatric unit is not necessary based solely on the consumption of wine with phenelzine; assessing the client's condition is the priority.
C. Discussing the effects of wine on the action of antidepressants is important, but assessing the client's current status takes precedence.
D. Assessing the client's blood pressure is the priority action because phenelzine is an MAOI, and consuming wine while taking MAOIs can lead to a hypertensive crisis.
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