Patient Data

Exhibits

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
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and the blood pressure changes are the result of
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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason:

Polyuria, or excessive urination, is a symptom of diabetes insipidus rather than a side effect of vasopressin. Vasopressin is used to reduce urine output in DI patients. If polyuria persists, it may indicate that the medication is not effective, but it is not a direct side effect that requires immediate reporting.

Choice B Reason:

Low urine specific gravity indicates dilute urine, which is a characteristic of diabetes insipidus. Vasopressin should help concentrate the urine. If low urine specific gravity persists, it may suggest that the medication is not working effectively, but it is not a side effect that necessitates urgent reporting.

Choice C Reason:

Polydipsia, or excessive thirst, is another symptom of diabetes insipidus. While vasopressin should help reduce this symptom by controlling urine output, persistent polydipsia may indicate inadequate treatment. However, it is not a side effect of the medication that requires immediate attention.

Choice D Reason:

Worsening headache is a significant side effect that should be reported to the healthcare provider. Headaches can indicate water intoxication or hyponatremia (low sodium levels), which are serious complications of vasopressin therapy. Immediate reporting is necessary to adjust the treatment and prevent further complications.

A. Count the apical and radial pulses simultaneously. B. Observe for edema around the ankles. C. Auscultate the client’s bowel sounds. D. Measure the client’s capillary glucose level.

Correct Answer is C

Explanation

Choice A reason:

Counting the apical and radial pulses simultaneously can help detect pulse deficits, which may indicate cardiac issues. However, this is not the most critical assessment for a client receiving hydromorphone.

Choice B reason:

Observing for edema around the ankles is important for assessing fluid retention and potential heart failure. While relevant, it is not the primary concern for a client on hydromorphone.

Choice C reason:

Auscultating the client’s bowel sounds is crucial because hydromorphone, like other opioids, can cause constipation and potentially lead to paralytic ileus, a serious condition where the intestines stop moving food through. Monitoring bowel sounds helps detect early signs of this complication.

Choice D reason:

Measuring the client’s capillary glucose level is important for diabetic patients or those at risk of hyperglycemia. However, it is not directly related to the administration of hydromorphone.

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Naxlex Comprehensive Predictor Exams

A client who is newly diagnosed with diabetes insipidus (DI) is receiving synthetic vasopressin intravenously. Which side effect of vasopressin reported by the client should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

The nurse notes that a client has been receiving hydromorphone every six hours for four days. Which assessment is most important for the nurse to complete?

Correct Answer is C

Explanation

The nurse is providing discharge instructions to a client who has been prescribed gabapentin 300 mg by mouth (PO) three times a day for postherpetic neuralgia. Which symptom should the nurse tell the client to report to the healthcare provider?

The healthcare provider prescribes propylthiouracil (PTU) and Lugol’s solution, a strong iodine solution, for a client with hyperthyroidism. How should the nurse schedule the administration of these medications?

Patient Data Exhibits Which assessment findings require follow-up by the nurse? Select all that apply.

Patient Data Exhibits The healthcare provider (HCP) has given the client a prescription for captopril. Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Captopril is a(n) dropdown that works by dropdown.

A glucagon emergency kit is prescribed for a client with type 1 diabetes mellitus. When should the nurse instruct the client and family that glucagon needs to be administered?

The nurse notifies the healthcare provider (HCP) that the client is having trouble remembering to take his second dose of captopril. What angiotensin-converting enzyme (ACE) inhibitors can be given only once per day? Select all that apply.

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 half-marathon. Which instruction should the nurse emphasize?