The nurse is caring for a client who has been taking aspirin 81mg PO daily for the last six months. Which clinical findings are of most concern? (SELECT ALL THAT APPLY)

Temperature elevation of 100.4 ORGAN

Hemoglobin decrease from 128g/dl to 9.5g/dl

Serum potassium increase from 3.5 mEq/L 4.5 mEq/L

Gastrointestinal discomfort prior to eating breakfast

Several areas of ecchymosis on upper and lower extremities

Answer and Explanation

Correct Answer : B,E

A. Temperature elevation of 100.4°F: While a slight fever can indicate infection or inflammation, it is not an immediate concern related to aspirin use. It requires monitoring but is not as critical as other findings.

B. Hemoglobin decrease from 128 g/dL to 5.5 g/dL: This significant drop in hemoglobin indicates severe anemia, which is a major concern and may suggest gastrointestinal bleeding, a known risk of long-term aspirin use.

C. Serum potassium increase from 3.5 mEq/L to 4.5 mEq/L: This level is still within the normal range and does not indicate a significant clinical issue. Normal potassium levels do not raise immediate concern.

D. Gastrointestinal discomfort prior to eating breakfast: While gastrointestinal discomfort can be a side effect of aspirin, it is not immediately alarming unless associated with more severe symptoms like bleeding or ulceration.

E. Several areas of ecchymosis on upper and lower extremities: This finding is concerning as it may indicate bleeding issues due to thrombocytopenia or increased bleeding tendency associated with aspirin therapy.

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Correct Answer is C

Explanation

A. "I should continue to read the labels of foods I select in the grocery store.": This statement is appropriate as reading labels helps the client avoid high sodium and unhealthy fats, which can negatively impact blood pressure.

B. "When I get out of bed in the morning, I should first sit for a few minutes and then stand.": This statement reflects a good understanding of managing potential orthostatic hypotension, which can occur with antihypertensive medications. It indicates awareness of the need to rise slowly to prevent dizziness.

C. "I will be able to stop my anti-hypertensive medication when my blood pressure is normal.": This statement indicates a need for clarification. Many patients believe that once their blood pressure is normal, they can discontinue medication, but hypertension is often a chronic condition that requires ongoing management to maintain blood pressure control.

D. "Keeping my blood pressure under control reduces my risk for a heart attack.": This statement is accurate and demonstrates an understanding of the importance of hypertension management in reducing cardiovascular risk.

A. working on an arithmetic quiz for 20 minutes without getting out of their seat B. family members report no episodes of pica C. does not tell untrue information D. completing a jigsaw puzzle with a friend E. decreased manipulative behaviors

Correct Answer is ["A","D","E"]

Explanation

A) Working on an arithmetic quiz for 20 minutes without getting out of their seat: This outcome indicates improved focus and attention span, which are desired effects of methylphenidate in managing ADHD symptoms. The ability to stay seated and concentrate on a task for an extended period is a positive sign of the medication’s effectiveness.

B) Family members report no episodes of pica: Pica, the consumption of non-food items, is not typically associated with ADHD. Therefore, the absence of pica episodes is not a relevant outcome for evaluating the effectiveness of methylphenidate in this context.

C) Does not tell untrue information: While honesty is important, it is not a primary focus of ADHD treatment. Methylphenidate aims to improve attention, focus, and reduce hyperactivity, rather than directly addressing truthfulness.
D) Completing a jigsaw puzzle with a friend: Successfully completing a jigsaw puzzle with a friend demonstrates improved attention, focus, and social interaction skills. These are positive outcomes of methylphenidate treatment for ADHD, indicating better management of hyperactivity and distractibility.

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The nurse is caring for a client who has been taking aspirin 81mg PO daily for the last six months. Which clinical findings are of most concern? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

Correct Answer is C

Explanation

A 10-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. After 5 weeks of methylphenidate, the nurse should monitor for which desired outcome? (SELECT ALL THAT APPLY)

Correct Answer is ["A","D","E"]

Explanation

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