Patient Data

Exhibits

Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

Nausea and vomiting

Fatigue and weakness

Bradycardia

Visual disturbances (e.g., yellow-green halos)

Hypertension

Answer and Explanation

Correct Answer : A,B,C,D

A. Nausea and vomiting: Gastrointestinal symptoms such as nausea, vomiting, and anorexia are common early signs of digoxin toxicity and should be closely monitored.

B. Fatigue and weakness: Generalized fatigue and muscle weakness can result from digoxin toxicity due to its effects on cardiac output and electrolyte imbalances, indicating early toxicity.

C. Bradycardia: Digoxin increases vagal tone, which can lead to bradycardia. A heart rate below 60 bpm is a key warning sign of digoxin toxicity.

D. Visual disturbances (e.g., yellow-green halos): Visual changes, including blurred vision, yellow-green halos, or altered color perception, are classic manifestations of digoxin toxicity and require prompt recognition.

E. Hypertension: Hypertension is not typically associated with digoxin toxicity; digoxin more commonly causes bradyarrhythmias and hypotension rather than elevated blood pressure.

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Correct Answer is A

Explanation

A. Engage the client in non-threatening conversations: Establishing a therapeutic nurse–client relationship through simple, supportive communication helps reduce isolation, builds trust, and may encourage the client to begin expressing thoughts and feelings.

B. Encourage the client's family to visit more often: Family involvement can be beneficial, but it may not be effective if the client is withdrawn. Increasing visits without first fostering a supportive environment could overwhelm or further isolate the client.

C. Encourage the client to participate in group activities: Group activities promote social interaction but may feel intimidating or threatening for someone who has been withdrawn for weeks. Gradual re-engagement beginning with one-on-one communication is more appropriate.

D. Schedule a daily conference with the social worker: Involving the social worker can be helpful for comprehensive care planning, but this does not directly address the immediate nursing priority of engaging the client therapeutically and reducing withdrawal.

A. Instruct incentive spirometry use every hour. B. Use petroleum based lotion on skin. C. Administer antibiotics. D. Suggest that client ambulate often. E. Encourage consumption of protein and vitamin C. F. Apply thromboembolism deterrent stockings (TED).

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Rationale:

• Instruct incentive spirometry use every hour: Indicated to promote lung expansion and prevent complications such as pneumonia or atelectasis. Even though the infection is in the leg, maintaining adequate oxygenation and pulmonary function is critical in older adults with multiple comorbidities.

• Use petroleum-based lotion on skin: Contraindicated because petroleum-based products can trap moisture and bacteria, increasing the risk of worsening cellulitis or skin breakdown. Non-occlusive, water-based moisturizers are safer for diabetic or infected skin.

• Administer antibiotics: Indicated as the client has a bacterial infection (cellulitis) with erythema, warmth, swelling, and elevated WBC count. IV cefazolin is prescribed to treat the infection promptly and prevent progression to sepsis.

• Suggest that client ambulate often: Contraindicated because the affected leg is inflamed, painful, and at risk for injury or worsening edema. Early ambulation may exacerbate discomfort and impair healing; activity should be gradual and guided by pain tolerance and clinical stability.

• Encourage consumption of protein and vitamin C: Indicated to support wound healing and immune function. Adequate protein and vitamin C intake are essential for tissue repair and recovery from infection, particularly in older adults with chronic comorbidities.

• Apply thromboembolism deterrent stockings (TED): Indicated to prevent venous thromboembolism, especially since the client has limited mobility due to pain and swelling, advanced age, and comorbid conditions like heart failure and diabetes.

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Patient Data Exhibits Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Patient Data Exhibits For each potential nursing action, click to indicate whether the action is indicated, contraindicated, or nonessential for this client's plan of care. Each row must have only one option selected.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

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Patient Data

Exhibits

Which of the following findings should the nurse recognize as manifestations of digoxin toxicity? (Select all that apply.)