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 D

Explanation

A. Offer to discuss the client's health status with each of the adult children: While involving family in discussions is important, the immediate question from the spouse is about recognizing signs of imminent death. Directly explaining the physiological changes is more appropriate at this moment.

B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children: Waiting for the HCP to give a signal does not provide the spouse with the knowledge they are seeking. It may delay preparation and increase anxiety during the final hours.

C. Gather information regarding how long it will take for the children to arrive: While logistical planning is helpful, it does not address the spouse’s question about recognizing imminent death and understanding what to expect.

D. Explain that the client will start to lose consciousness and the body systems will slow down: Providing clear, compassionate information about the expected signs of dying helps the spouse recognize that death is near, allows family members to prepare emotionally, and facilitates meaningful final interactions with the client.

A. Palpate the client's suprapubic area for distention. B. Instruct in effective techniques to cleanse the glans penis. C. Obtain a urine specimen for culture and sensitivity. D. Advise the client to maintain a voiding diary for one week.

Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: Palpating for bladder distention helps determine if urinary retention is present, which is common in older men with possible benign prostatic hyperplasia (BPH). Assessing retention is a priority because unresolved urinary obstruction can lead to hydronephrosis or kidney damage.

B. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important for preventing infection, especially in uncircumcised males, but it does not address the client’s primary problem of urinary retention and obstructive symptoms.

C. Obtain a urine specimen for culture and sensitivity: While urinary tract infections can occur in clients with urinary retention, the presenting symptoms here are more indicative of obstruction due to prostate enlargement. A culture may be ordered later, but not the first step.

D. Advise the client to maintain a voiding diary for one week: A voiding diary provides helpful long-term information about urinary patterns, but it does not address the acute issue of a bladder that may be distended and retaining urine.

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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.)

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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.)