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) Drain the tub water before the client gets out: Draining the water before the client gets out of the tub is the safest option. This helps prevent the risk of slipping or falling, as the water level will lower once the client begins to stand. Additionally, it ensures that the client can safely exit the tub without the danger of being unbalanced or disoriented by the water.
B) Check on the client every 10 min during the bath: While monitoring the client during the bath is important, checking every 10 minutes may not be frequent enough to ensure their safety, especially for clients who have mobility or cognitive issues. Ideally, the nurse should stay with or observe the client more closely or provide assistance if needed. Continuous supervision is preferred, particularly if the client is at risk for falls or other complications.
C) Add bath oil to the water after the client gets into the tub: Bath oils can create a slippery surface, which could increase the risk of falls or accidents. It's generally better to avoid adding oils to the bath water, as they can make the tub and the client’s skin slick, posing safety hazards. If oil is necessary for skin care, it should be applied to the skin after the bath, not in the water.
D) Allow the client to remain in the bath for 30 min: While the client may enjoy a bath, staying in the tub for too long can lead to skin irritation, dehydration, or overheating, especially for older adults or clients with medical conditions. The client should not stay in the water for prolonged periods. A typical recommendation would be to allow the bath to last about 10-20 minutes, depending on the client’s condition and safety.
Correct Answer is ["A","B","C"]
Explanation
A. "I can expect my contact lenses to turn red or orange.”
Rifampin causes red-orange discoloration of body fluids, including tears, sweat, urine, and saliva. This effect is harmless but can stain soft contact lenses permanently, so clients should be advised to use glasses instead.
B. “I should notify my provider if I start taking new over-the-counter or prescription medications.”
Rifampin is a potent enzyme inducer that can alter the metabolism of many drugs, including oral contraceptives and anticoagulants. The provider should be informed of any new medications to avoid potential drug interactions and ensure therapeutic effectiveness.
C. “I will need to have someone observe me when I take my medication.”
Directly observed therapy (DOT) is recommended to ensure adherence to tuberculosis treatment. A healthcare provider or designated individual supervises medication intake to improve compliance and reduce the risk of drug resistance.
D. “I will need to have a repeat Mantoux test in 4 weeks.”
A repeat Mantoux test is unnecessary for diagnosing active tuberculosis, as this condition is confirmed through sputum cultures and chest X-ray findings. Mantoux testing is primarily used for screening latent TB infections.
E. “I am no longer contagious.”
Clients with active tuberculosis remain contagious until they complete at least two weeks of effective multidrug therapy and show clinical improvement. Until then, infection control measures such as respiratory isolation should be followed.
F. “I will need to take my medications for a total of 6 weeks.”
The standard treatment for active tuberculosis lasts at least six months, typically involving a four-drug regimen for the first two months, followed by two drugs for the remaining four months. A six-week course is insufficient for eradication.
G. "I can continue my current alcohol intake."
Alcohol should be avoided due to the hepatotoxic effects of isoniazid, rifampin, and pyrazinamide. Combining alcohol with these medications increases the risk of liver damage, requiring clients to abstain or limit intake.
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