The nurse is caring for a patient taking a cholinergic agent. When auscultating lung sounds, the nurse notes inspiratory and expiratory wheezing bilaterally. The best action for the nurse to take would be to:

withhold the next dose and notify the physician

give the next dose

assess heart rate

assess blood pressure

Answer and Explanation

The Correct Answer is A

A. Withhold the next dose and notify the physician:

Withholding the next dose of the cholinergic agent is the appropriate immediate action because the presence of inspiratory and expiratory wheezing bilaterally suggests bronchoconstriction or bronchospasm, which can be a serious adverse reaction to the medication. Notifying the physician promptly allows for further assessment and management of the patient's respiratory symptoms. The physician may need to adjust the medication regimen, order diagnostic tests, or provide treatment for bronchoconstriction.

B. Give the next dose:

Administering the next dose of the cholinergic agent could worsen the patient's respiratory symptoms and exacerbate bronchoconstriction. This action is contraindicated in the presence of wheezing, as it may further compromise the patient's respiratory function.

C. Assess heart rate:

While assessing heart rate is an important aspect of patient assessment, it is not the priority in this scenario. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing is a respiratory symptom that suggests airway obstruction, and immediate intervention is necessary to ensure adequate oxygenation and ventilation.

D. Assess blood pressure:

Similarly, while assessing blood pressure is important in patient care, it is not the priority in this situation. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing indicates respiratory compromise, and prompt action is required to prevent further respiratory deterioration.

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Correct Answer is A

Explanation

A. Orthostatic hypotension:

Orthostatic hypotension, a sudden drop in blood pressure when standing up, is a potential adverse effect of levodopa therapy. This can lead to dizziness and increase the risk of falls, thus supporting the nursing diagnosis Risk for Injury.

B. Nausea and vomiting:

Nausea and vomiting are common side effects of levodopa therapy. While they can cause discomfort and dehydration, they are less directly related to the risk of physical injury compared to orthostatic hypotension.

C. Anorexia and depression:

Anorexia (loss of appetite) and depression can occur as adverse effects of levodopa therapy. While they can affect the patient's overall well-being and quality of life, they are not directly associated with an increased risk of physical injury.

D. Tachycardia and palpitations:

Tachycardia (rapid heart rate) and palpitations are less common adverse effects of levodopa therapy. While they may indicate cardiovascular issues, they are not typically associated with a direct risk of physical injury.

A. Semicomatose B. Somnolent C. Lethargic D. Comatose

Correct Answer is C

Explanation

A. Semicomatose:

This term suggests a state between consciousness and coma. A patient who is semicomatose may exhibit some level of responsiveness but is typically unresponsive or only responds to intense stimuli.

B. Somnolent:

Somnolence refers to a state of drowsiness or sleepiness. A somnolent patient may appear sleepy, have difficulty staying awake, and may be slow to respond to stimuli. However, the withdrawal from painful stimuli described in the scenario suggests a higher level of responsiveness than what would typically be expected in a somnolent state.

C. Lethargic:

Lethargy describes a state of reduced alertness or responsiveness. A lethargic patient may appear drowsy, sluggish, and have diminished responses to stimuli. The description of the patient as stuporous (having a decreased level of consciousness) but still reacting by withdrawing from painful stimuli aligns with the characteristics of lethargy.

D. Comatose:

Coma refers to a state of profound unconsciousness where the patient is unresponsive to all stimuli, including painful stimuli. A comatose patient does not demonstrate any purposeful movement or response to stimuli. Since the patient in the scenario exhibits some response to painful stimuli by withdrawing, they do not meet the criteria for being comatose.

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The nurse is caring for a patient taking a cholinergic agent. When auscultating lung sounds, the nurse notes inspiratory and expiratory wheezing bilaterally. The best action for the nurse to take would be to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which adverse effects associated with levodopa therapy would support the nursing diagnosis Risk for Injury?

Correct Answer is A

Explanation

A patient is stuporous but reacts by withdrawing from painful stimuli. Which term is most appropriate for this patient?

Correct Answer is C

Explanation

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