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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "These drugs inhibit the action of acetylcholine":
This response is accurate. Anticholinergic medications work by blocking the action of acetylcholine, a neurotransmitter involved in various functions in the body, including muscle control. In Parkinson's disease, there is an imbalance between dopamine and acetylcholine, leading to motor symptoms such as tremors and rigidity. By inhibiting the action of acetylcholine, anticholinergic drugs help rebalance neurotransmitter activity and alleviate some of the motor symptoms associated with Parkinson's disease.
B. "These drugs help you urinate":
This statement is not directly related to the use of anticholinergic medications in Parkinson's disease. While some anticholinergic drugs can indeed relax the smooth muscle of the bladder and improve urinary symptoms, this is not the primary indication for their use in Parkinson's disease.
C. "These drugs will decrease your eye pressure":
While anticholinergic medications can be used to dilate the pupils and decrease intraocular pressure, this is not typically the reason for their use in Parkinson's disease. While some anticholinergic medications may have ocular effects, they are primarily used to address motor symptoms associated with Parkinson's disease.
D. "These drugs will assist in lowering your heart rate":
While some anticholinergic medications may have effects on heart rate by blocking parasympathetic nervous system activity, this is not the primary indication for their use in Parkinson's disease. The focus of anticholinergic therapy in Parkinson's disease is primarily on addressing motor symptoms rather than cardiovascular effects.
Correct Answer is D
Explanation
A. Dizziness and problems with balance
While dizziness and problems with balance can occur more frequently in older adults due to age-related changes in the vestibular system and other factors, persistent or severe dizziness or balance issues should be evaluated further as they could indicate underlying neurological or medical conditions.
B. Slow papillary response to light
This finding may be considered abnormal, especially if it represents a significant change from the individual's baseline. While age-related changes in pupil function can occur, a slow or sluggish pupillary response to light may indicate dysfunction of the oculomotor nerve or other neurological issues and should be investigated further.
C. Jerky eye movements
Jerky eye movements, such as nystagmus, can be abnormal and may indicate dysfunction of the vestibular system or other neurological conditions. While some degree of nystagmus can occur with age, persistent or severe jerky eye movements should be evaluated further.
D. Absence of the Achilles tendon jerk
This finding may also be considered abnormal. The Achilles tendon reflex, tested using the deep tendon reflex (DTR) examination, can diminish with age but should not be completely absent in the absence of specific medical conditions affecting the reflex arc or spinal cord function.
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