The nurse is administering medications to the client and is monitoring potential adverse effects of medications.
For each body system below, click to specify the assessment findings that could indicate a serious adverse reaction. Each body system may support more than 1 potential assessment finding. To deselect a finding click on the finding again.
Body system |
Findings |
Head. Eyes. Ears. Nose, and Throat (HEENT) |
Yellowing of the eyes Blurred vision Dry eyes |
Gastrointestinal |
Abdominal pain Weight gain |
Hematologic |
Increased bruising Increased bleeding tendancies Insomnia |
Genitourinary |
Darkening of the urine Urinary frequency |
Yellowing of the eyes
Blurred vision
Dry eyes
Abdominal pain
Weight gain
Increased bruising
Increased bleeding tendancies
Insomnia
Darkening of the urine
Urinary frequency
The Correct Answer is ["A","B","D","F","G","I"]
Yellowing of the eyes (Jaundice) → Isoniazid and Rifampin can cause hepatotoxicity, leading to jaundice.
Blurred vision → Ethambutol can cause optic neuritis, leading to blurred vision and color blindness.
Dry eyes (Incorrect) → Not a common side effect of TB medications.
Gastrointestinal:
Abdominal pain → Isoniazid, Rifampin, and Pyrazinamide are hepatotoxic and can cause liver inflammation and gastric irritation.
Weight gain (Incorrect) → TB medications are more likely to cause weight loss rather than gain.
Hematologic:
Increased bruising & bleeding tendencies → Rifampin can cause thrombocytopenia, increasing the risk of bruising and bleeding.
Insomnia (Incorrect) → Not a serious adverse effect of TB medications.
Genitourinary:
Darkening of the urine → Rifampin causes orange-red discoloration of urine, sweat, and tears, which is a benign but expected effect.
Urinary frequency (Incorrect) → Not a known adverse effect of TB medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Position the client’s head toward Mecca: In Islam, it is customary to position the deceased's body with the head facing toward Mecca, the holy city of Islam. This is an important religious practice and should be followed during postmortem care to respect the deceased's cultural and religious beliefs.
B) Allow a family member of the client to stay with the client’s body until burial: It is customary in many Islamic traditions for a family member to stay with the body, providing comfort and ensuring the body is treated with respect. However, the nurse should ensure this is done within the hospital's policies and in a safe, culturally sensitive manner. This practice should be respected, but it is not the immediate priority for the nurse during postmortem care.
C) Allow a family member to stay with the client’s body for 8hr: While some Islamic traditions may involve family members staying with the body, the nurse should adhere to the specific wishes of the family and the institution's policies. The 8-hour duration is not a specific religious requirement, and the focus should be on providing respectful, appropriate care and ensuring the family’s wishes are honored within the hospital's guidelines.
D) Position the client’s head northward: In Islamic traditions, the body is positioned with the head facing toward Mecca, not northward. Positioning the head in a direction other than toward Mecca would not align with the cultural practices of Islam regarding postmortem care. Therefore, this action would not be appropriate.
Correct Answer is A
Explanation
A) Irregular heart rate: An irregular heart rate is a key manifestation of hyperkalemia. Elevated potassium levels can interfere with the normal electrical activity of the heart, leading to arrhythmias, which can cause an irregular heart rate. In severe cases, hyperkalemia can lead to life-threatening cardiac events such as ventricular fibrillation or asystole.
B) Dry mucous membrane: Dry mucous membranes are more commonly associated with dehydration, not hyperkalemia. Dehydration can cause fluid volume depletion, which leads to dry mouth and other signs of insufficient hydration. While renal failure can lead to fluid balance issues, dry mucous membranes are not typically linked to elevated potassium levels.
C) Trousseau's sign: Trousseau's sign is a clinical indicator of hypocalcemia, not hyperkalemia. It is a spasm of the hand and wrist that occurs when a blood pressure cuff is inflated above systolic pressure for several minutes. This sign suggests low calcium levels, and while calcium imbalance can occur in renal failure, it is unrelated to hyperkalemia.
D) Hyperactive reflexes: Hyperactive reflexes are more commonly associated with conditions like hypocalcemia, rather than hyperkalemia. In hyperkalemia, the typical findings include muscle weakness or paralysis due to the effect of potassium on muscle and nerve function, but hyperactive reflexes would not be expected.
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