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The nurse is reviewing the client's prescriptions.

Exhibits

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 tendency

Insomnia

Genitourinary

Darkening of the urine

Urinary frequency

Yellowing of the eyes

Blurred vision

Dry eyes

Abdominal pain

Weight gain

Increased bruising

Increased bleeding tendency

Insomnia

Darkening of the urine

Urinary frequency

Answer and Explanation

The Correct Answer is ["A","B","D","F","G","I"]

Rationale for Correct Options:

Yellowing of the eyes: Indicates hepatotoxicity, a serious adverse effect of isoniazid, rifampin, and pyrazinamide. These drugs can cause liver damage, leading to jaundice, which presents as yellowing of the eyes and skin. Liver function tests should be monitored closely.
Blurred vision: Can result from optic neuritis, a known adverse effect of ethambutol. Ethambutol can damage the optic nerve, causing visual disturbances, including decreased visual acuity and color blindness. Patients should undergo routine eye exams.
Abdominal pain: May indicate hepatotoxicity from TB medications, particularly isoniazid, rifampin, and pyrazinamide. Liver inflammation or damage can manifest as right upper quadrant pain, nausea, and loss of appetite. Monitoring liver enzymes is essential.
Increased bruising: Can result from thrombocytopenia, a hematologic side effect of rifampin. Rifampin can suppress bone marrow function, leading to reduced platelet production, increasing the risk of spontaneous bruising and prolonged bleeding.
Increased bleeding tendency: Suggests liver dysfunction, as the liver is responsible for producing clotting factors. Rifampin-induced hepatotoxicity can impair clotting mechanisms, increasing the risk of excessive bleeding from minor injuries.
Darkening of the urine: A common but harmless side effect of rifampin. Rifampin is excreted in bodily fluids, causing orange or red discoloration of urine, sweat, and tears. Patients should be educated on this expected effect to prevent unnecessary concern.

Rationale for Incorrect Options:

Dry eyes: Not associated with TB medications and may be due to environmental factors or dehydration.
Weight gain: Unlikely with TB treatment, as these medications typically cause weight loss rather than weight gain.
Insomnia: Not a significant adverse effect of first-line TB drugs and may be related to the client’s illness or other factors.
Urinary frequency: Not a common reaction to TB medications, as these drugs do not significantly affect renal function or bladder activity.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Medical health insurance claims. While insurance coverage is important for referral approval, the physical therapist primarily requires clinical information related to the client's mobility and functional status. Insurance details are handled by administrative staff rather than included in the clinical referral.
B. Physical assessment findings. The physical therapist needs relevant assessment findings, such as muscle strength, range of motion, balance, gait, and mobility limitations. These details help guide therapy goals and interventions to improve the client’s functional abilities.
C. Family medical history. While family history is useful for identifying genetic predispositions to conditions, it is not essential for a physical therapy referral. The focus should be on the client’s current physical status rather than hereditary factors.
D. Medications taken prior to admission. Although a client’s medication history is important for overall care, it is not the primary concern for a physical therapy referral unless specific medications affect mobility, such as muscle relaxants or sedatives. The therapist will rely more on current physical assessment findings to determine appropriate interventions.

A. Case manager B. Primary care provider C. Nutritionist D. Pediatric nurse practitioner

Correct Answer is A

Explanation

A. Case manager. A case manager assists clients in accessing community resources, including financial assistance programs such as WIC (Women, Infants, and Children) and other social services that provide formula for infants. This referral ensures the client receives the necessary support to meet her baby's nutritional needs.
B. Primary care provider. A primary care provider focuses on the client’s medical care rather than financial or social concerns. While they may provide guidance on infant nutrition, they are not the best resource for addressing the client’s financial difficulties in obtaining formula.
C. Nutritionist. A nutritionist provides dietary guidance but does not handle financial assistance programs. They may educate the client on proper infant feeding, but they cannot directly assist with obtaining formula for a client who cannot afford it.
D. Pediatric nurse practitioner. A pediatric nurse practitioner specializes in infant health but does not typically manage financial concerns. They may assess the baby’s growth and nutritional needs but would refer the client to a case manager or social services for formula assistance.

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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 tendency Insomnia
Genitourinary	Darkening of the urine Urinary frequency

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?

Correct Answer is B

Explanation

A nurse is collecting data from a client who is 2 days postpartum. The client tells the nurse she cannot afford to pay for baby formula. The nurse should refer the client to which of the following members of the interprofessional team?

Correct Answer is A

Explanation

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