The adverse effects of xanthene are related to the theophylline levels in the blood and include brain damage.

Choice A rationale

Increased jugular venous pressure is more commonly associated with right-sided heart failure, where blood backs up into the venous system.

Choice B rationale

Liver enlargement is also indicative of right-sided heart failure due to congestion of the liver blood vessels.

Choice C rationale

Increased pulse rate can occur in both left and right-sided heart failure but is not a specific indicator of worsening left-sided failure.

Choice D rationale

Increased crackles in lung fields indicate fluid accumulation in the lungs, a sign of worsening left-sided heart failure. Left-sided heart failure leads to pulmonary congestion due to inadequate pumping of blood from the left ventricle.

Choice A rationale

This choice is incorrect. Although knowledge about drug therapy is important, it is not the most immediate concern in this scenario. The priority nursing diagnosis should address the potential risks associated with the drug’s side effects, such as sedation, which can impair the patient’s ability to function safely.

Choice B rationale

This choice is incorrect. While effective health maintenance and medication adherence are crucial, they do not directly address the immediate risk posed by the drug’s sedative effects. The priority should be to prevent harm and ensure the patient’s safety, which involves mitigating the risk of injury related to sedation.

Choice C rationale

This choice is correct. The primary concern with sedative drugs, especially in elderly patients, is the increased risk of falls and injuries due to impaired coordination and alertness. The nursing diagnosis “Risk for injury, related to adverse effect of the drug” directly addresses this critical issue, making it the priority in this situation.

Choice D rationale

This choice is incorrect. Noncompliance due to the cost of the drug is an important consideration, but it does not address the immediate safety risk posed by sedation. The priority should be to ensure the patient’s safety by managing the side effects that could lead to injury. Cost-related concerns can be addressed after ensuring that the patient is not at immediate risk of harm. .