Patient Data
The nurse is assessing the client to update the plan of care. Choose the most likely options for the information missing from the statement by selecting from the lists of options provided.
The nurse determines that the client is experiencing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Choice A: Syncope
Reason: Syncope, or fainting, is a temporary loss of consciousness typically caused by a drop in blood flow to the brain. The client has a history of symptomatic bradycardia, which is a slow heart rate that can lead to insufficient blood flow and oxygen to the brain, causing syncope. The client reported passing out once due to a low heart rate, which aligns with the symptoms of syncope. Bradycardia can cause a significant drop in cardiac output, leading to decreased cerebral perfusion and resulting in fainting episodes.
Choice B: Hypovolemic Shock
Reason: Hypovolemic shock occurs when there is a significant loss of blood or fluids, leading to decreased blood volume and inadequate tissue perfusion. Symptoms include rapid heartbeat, low blood pressure, and confusion. However, the client’s history and current condition do not indicate any significant blood or fluid loss. The primary issue is related to the heart’s electrical activity and rate, not volume loss.
Choice C: Heart Failure
Reason: Heart failure is a condition where the heart cannot pump blood effectively, leading to symptoms like shortness of breath, fatigue, and fluid retention. While the client has a history of atrial fibrillation, which can contribute to heart failure, the immediate concern is the symptomatic bradycardia causing syncope. The client’s symptoms of low heart rate and fainting are more directly related to bradycardia rather than heart failure.
Choice D: Adverse Drug Reaction
Reason: An adverse drug reaction could cause various symptoms, including changes in heart rate and blood pressure. However, the client has not reported any new medications or changes in her current regimen that would suggest an adverse reaction. The symptoms described are consistent with her known condition of bradycardia.
Choice A: Anxiety
Reason: Anxiety can cause various physiological responses, including increased heart rate and blood pressure. However, the client’s primary issue is a low heart rate, which is not typically associated with anxiety. Anxiety might exacerbate symptoms but is not the root cause of the blood pressure changes in this case.
Choice B: Antibiotic
Reason: While antibiotics can cause side effects, they are not typically associated with significant changes in blood pressure. The vancomycin administered was for endocarditis prophylaxis and is unlikely to be the cause of the blood pressure changes observed.
Choice C: IV Infiltration
Reason: IV infiltration occurs when IV fluids leak into the surrounding tissue, causing swelling, pain, and potential tissue damage. While this can cause localized issues, it is not typically associated with systemic blood pressure changes. The client’s symptoms are more consistent with a systemic issue related to her heart condition.
Choice D: Vasodilation
Reason: Vasodilation refers to the widening of blood vessels, which can lead to a drop in blood pressure. This can occur as a response to various factors, including medications, heat, or a physiological response to low blood flow. In the context of bradycardia, the body’s compensatory mechanisms might include vasodilation to improve blood flow, which can result in lower blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}
Explanation
Choice A: Capillary refill 2 seconds
Reason: Capillary refill time is a quick test to assess peripheral perfusion and hydration status. A normal capillary refill time is less than 2 seconds. Initially, the patient had a capillary refill time of 5 seconds, indicating poor perfusion, likely due to dehydration from vomiting and diarrhea. After the administration of IV fluids and sodium bicarbonate, the capillary refill time improved to 2 seconds, which is within the normal range. This improvement indicates that the treatment was effective in restoring adequate perfusion and hydration, making it a therapeutic result.
Choice B: Blood pressure 113/72 mm Hg
Reason: Normal blood pressure for adults is typically around 120/80 mm Hg. The patient’s initial blood pressure was 100/77 mm Hg, which is on the lower side, likely due to dehydration. After receiving IV fluids and sodium bicarbonate, the blood pressure improved to 113/72 mm Hg, which is closer to the normal range. This indicates that the treatment helped to stabilize the patient’s blood pressure, making it a therapeutic result.
Choice C: Bicarbonate 22 mEq/L (22 mmol/L)
Reason: The normal range for bicarbonate (HCO3) is 21 to 28 mEq/L. The patient’s initial bicarbonate level was 15 mEq/L, indicating metabolic acidosis, likely due to severe vomiting and diarrhea. After the administration of sodium bicarbonate, the bicarbonate level increased to 22 mEq/L, which is within the normal range. This indicates that the sodium bicarbonate effectively corrected the metabolic acidosis, making it a therapeutic result.
Choice D: Sodium 152 mEq/L (152 mmol/L)
Reason: The normal range for sodium is 135 to 145 mEq/L. The patient’s sodium level of 152 mEq/L is above the normal range, indicating hypernatremia. This could be a non-therapeutic side effect of the sodium bicarbonate administration, as sodium bicarbonate can increase sodium levels in the blood. Hypernatremia can lead to symptoms such as confusion, muscle twitching, and seizures, and requires careful monitoring and management.
Choice E: 400 mL urine output
Reason: The patient’s urine output of 400 mL is not directly related to the administration of sodium bicarbonate. Urine output is influenced by various factors, including fluid intake, kidney function, and overall hydration status. In this case, the urine output is more likely related to the patient’s overall fluid balance and hydration status rather than a direct effect of the sodium bicarbonate. Therefore, it is considered an unrelated finding.
Choice F: Heart rate 77 beats/minute
Reason: A normal resting heart rate for adults ranges from 60 to 100 beats per minute. The patient’s initial heart rate was 102 beats per minute, which is elevated, likely due to dehydration and metabolic acidosis. After receiving IV fluids and sodium bicarbonate, the heart rate decreased to 77 beats per minute, which is within the normal range. This indicates that the treatment helped to stabilize the patient’s heart rate, making it a therapeutic result.
Correct Answer is B
Explanation
Choice A reason:
Performing a bladder scan is useful for assessing urinary retention, which can be a symptom of benign prostatic hyperplasia (BPH). However, it is not the primary method for monitoring adverse reactions to tamsulosin. Tamsulosin is an alpha-1 blocker that relaxes the muscles in the prostate and bladder neck, improving urine flow. While it can help reduce urinary retention, the primary concern with tamsulosin is its effect on blood pressure.
Choice B reason:
Monitoring blood pressure is crucial because tamsulosin can cause orthostatic hypotension, a condition where blood pressure drops significantly when a person stands up from a sitting or lying position. This can lead to dizziness, lightheadedness, and even fainting. Regular monitoring of blood pressure helps detect and manage this potential adverse reaction, ensuring the client’s safety.
Choice C reason:
Obtaining daily weights is important for monitoring fluid balance and detecting conditions like heart failure or kidney disease. However, it is not directly related to the adverse reactions of tamsulosin. The primary concern with tamsulosin is its impact on blood pressure, not fluid retention.
Choice D reason:
Assessing urine output is important for evaluating the effectiveness of tamsulosin in relieving urinary symptoms associated with BPH. However, it is not the primary method for monitoring adverse reactions. The main adverse reaction to be aware of with tamsulosin is its potential to cause orthostatic hypotension, making blood pressure monitoring the priority.
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