Patient Data
Which assessment findings require follow-up by the nurse? Select all that apply.
Myoclonus
Temperature 102°F (38.8°C)
Blood pressure 168/94 mm Hg
Altered mental status
Heart rate 118 beats/minute
Respirations 16 breaths/minute
Capillary refill
Diaphoresis
Lung sounds.
Correct Answer : A,B,C,D,E,H
Choice A: Myoclonus
Myoclonus refers to sudden, involuntary muscle jerks. In the context of this patient’s presentation, myoclonus is significant because it can be a symptom of serotonin syndrome, a potentially life-threatening condition that can occur with the use of serotonergic medications like paroxetine. Serotonin syndrome is characterized by a triad of cognitive, autonomic, and somatic effects, including altered mental status, autonomic instability, and neuromuscular abnormalities such as myoclonus. Therefore, the presence of myoclonus in this patient warrants immediate follow-up to rule out serotonin syndrome and initiate appropriate treatment if necessary.
Choice B: Temperature 102°F (38.8°C)
A temperature of 102°F (38.8°C) is indicative of a fever, which is an abnormal finding that requires follow-up. Fever can be a sign of infection or other inflammatory processes. In the context of this patient’s symptoms, including altered mental status and myoclonus, a high fever could also be a sign of serotonin syndrome. Normal body temperature ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C). A temperature above this range is concerning and requires further investigation to determine the underlying cause and appropriate intervention.
Choice C: Blood Pressure 168/94 mm Hg
The patient’s blood pressure of 168/94 mm Hg is significantly elevated. Normal blood pressure for adults is typically around 120/80 mm Hg. Hypertension can be a sign of autonomic instability, which is another component of serotonin syndrome. Elevated blood pressure can also increase the risk of cardiovascular events such as stroke or heart attack. Therefore, this finding requires follow-up to manage the patient’s blood pressure and address any underlying causes.
Choice D: Altered Mental Status
Altered mental status is a broad term that encompasses changes in cognitive function, including confusion, disorientation, and altered levels of consciousness. This patient’s altered mental status, combined with other symptoms such as fever and myoclonus, raises concern for serotonin syndrome. Altered mental status can also be caused by other conditions such as infections, metabolic disturbances, or neurological disorders. Immediate follow-up is necessary to determine the cause and provide appropriate treatment.
Choice E: Heart Rate 118 beats/minute
A heart rate of 118 beats per minute is considered tachycardia, which is an abnormally fast heart rate. The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Tachycardia can be a sign of autonomic instability, which is seen in conditions like serotonin syndrome. It can also be caused by fever, dehydration, or other underlying conditions. Follow-up is required to assess the cause of the tachycardia and manage it appropriately.
Choice F: Respirations 16 breaths/minute
A respiratory rate of 16 breaths per minute is within the normal range for adults, which is typically 12 to 20 breaths per minute. Therefore, this finding does not require immediate follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms.
Choice G: Capillary Refill
Capillary refill time of less than 3 seconds is considered normal. This indicates that the patient’s peripheral perfusion is adequate. Therefore, this finding does not require follow-up. However, it is important to continue monitoring for any changes in perfusion status.
Choice H: Diaphoresis
Diaphoresis, or excessive sweating, is another symptom that requires follow-up. It can be a sign of autonomic instability and is commonly seen in serotonin syndrome. Diaphoresis can also be associated with other conditions such as infections, hyperthyroidism, or anxiety. Given the patient’s other symptoms, it is important to investigate the cause of the diaphoresis and address it as part of the overall management plan.
Choice I: Lung Sounds
Lung sounds are noted to be clear, which is a normal finding. This indicates that there are no immediate respiratory issues such as pneumonia or pulmonary edema. Therefore, this finding does not require follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Asking if the client’s morning voids are dark-colored can help identify potential side effects of carbidopa-levodopa, such as darkened urine, which is a known but harmless side effect. However, this does not directly address the client’s concern about the medication’s effectiveness.
Choice B reason:
Evaluating the client for signs of dyskinesia is important because dyskinesia can be a side effect of long-term carbidopa-levodopa use. However, this step is more relevant after understanding the client’s specific concerns about the medication’s effectiveness.
Choice C reason:
Determining if the client is taking the medication before meals is crucial because food can affect the absorption of carbidopa-levodopa. Taking the medication on an empty stomach can enhance its effectiveness. However, this step should follow a more detailed exploration of the client’s concerns.
Choice D reason:
Exploring what the client means by the drug “is not working” is the most important first step. This allows the nurse to understand the client’s specific issues, whether they are related to symptom management, side effects, or other concerns. This information is essential for tailoring subsequent interventions and providing appropriate education and support.
Correct Answer is A
Explanation
Choice A reason:
Low-density lipoprotein (LDL) is often referred to as “bad” cholesterol because high levels can lead to plaque buildup in arteries and result in heart disease and stroke. Atorvastatin is a statin medication that works by reducing the production of cholesterol in the liver, specifically targeting LDL cholesterol. Lowering LDL levels is a primary goal in managing and reducing the risk of coronary artery disease.
Choice B reason:
High-density lipoprotein (HDL) is known as “good” cholesterol because it helps remove other forms of cholesterol from the bloodstream. While atorvastatin can also help increase HDL levels, the primary indicator of its effectiveness in reducing the risk of coronary artery disease is the reduction in LDL levels.
Choice C reason:
Prothrombin time (PT) is a measure of how long it takes blood to clot. It is not directly related to the effectiveness of atorvastatin in managing cholesterol levels or reducing the risk of coronary artery disease. PT is more relevant in the context of anticoagulant therapy.
Choice D reason:
Creatine phosphokinase (CK) is an enzyme found in the heart, brain, and skeletal muscles. Elevated CK levels can indicate muscle damage, which can be a side effect of statin therapy. However, CK levels are not used to measure the effectiveness of atorvastatin in lowering cholesterol or reducing the risk of coronary artery disease.
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