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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.

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Correct Answer is B

Explanation

A. Trousseau's sign indicates hypocalcemia, not hyperkalemia. It is assessed by inflating a blood pressure cuff around the upper arm and observing for muscle spasms in the hand and wrist, which is not related to potassium levels.
B. Irregular heart rate. Hyperkalemia can lead to cardiac dysrhythmias due to its effect on myocardial excitability and conduction. Elevated potassium levels can cause changes in the electrocardiogram (ECG), such as peaked T waves and prolonged PR intervals, which may result in an irregular heart rate and can be life-threatening if not addressed.
C. Hyperactive reflexes are typically associated with conditions such as hypercalcemia or neurological disorders, not hyperkalemia. Hyperkalemia can lead to decreased neuromuscular excitability and may present with muscle weakness or decreased reflexes.
D. Dry mucous membranes is more indicative of dehydration or a fluid volume deficit rather than hyperkalemia. Clients with renal failure may have fluid retention and edema due to impaired kidney function, which is contrary to the presentation of dry mucous membranes.

A. Diminished hearing B. Pupils C. Lung assessment D. Facial nerve assessment E. Vertigo F. Pain rating

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

Explanation

A. Diminished hearing. Hearing loss following a stapedectomy is expected due to postoperative swelling, packing in the ear, and fluid accumulation. Hearing typically improves as healing progresses. This does not require further action by the nurse.
B. Pupils. The preoperative and postoperative pupil assessments are similar (3.5 mm preoperatively and 3 mm postoperatively), and both are equal and reactive to light. No significant neurological change is noted, so this does not require further action.
C. Lung assessment. The lungs were clear bilaterally preoperatively, and there is no indication of respiratory compromise or abnormal lung sounds postoperatively. This does not require further action.
D. Facial nerve assessment. Facial nerve injury (cranial nerve VII dysfunction) is a potential complication of stapedectomy. The nurse should assess for asymmetry in facial movements such as difficulty smiling or drooping, weakness, or numbness, which could indicate facial nerve damage. This requires further action.
E. Vertigo. Postoperative vertigo and dizziness can occur due to disturbance of the inner ear during surgery. Severe or persistent vertigo may indicate labyrinthine injury or perilymph fistula, which could require medical intervention. This requires further action.
F. Pain rating. Postoperative pain is expected, but severe or increasing pain may indicate complications such as infection, excessive pressure in the middle ear, or improper prosthesis placement. Pain that is not relieved by analgesics requires further evaluation. This requires further action.

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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 is collecting data from a client who is in renal failure. The nurse should identify that which of the following findings is a manifestation of hyperkalemia?

Correct Answer is B

Explanation

Exhibits Which of the following findings requires further action by the nurse? Select all that apply.

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

Explanation

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