A 70-year-old patient has just received a drug that can cause sedation.
What would be the priority nursing diagnosis for this patient?
Deficient Knowledge, unfamiliar with drug therapy.
Ineffective health maintenance, need for medication.
Risk for injury, related to adverse effect of the drug.
Noncompliance, cost of the drug.
The Correct Answer is C
Choice A rationale
This choice is incorrect. Although knowledge about drug therapy is important, it is not the most immediate concern in this scenario. The priority nursing diagnosis should address the potential risks associated with the drug’s side effects, such as sedation, which can impair the patient’s ability to function safely.
Choice B rationale
This choice is incorrect. While effective health maintenance and medication adherence are crucial, they do not directly address the immediate risk posed by the drug’s sedative effects. The priority should be to prevent harm and ensure the patient’s safety, which involves mitigating the risk of injury related to sedation.
Choice C rationale
This choice is correct. The primary concern with sedative drugs, especially in elderly patients, is the increased risk of falls and injuries due to impaired coordination and alertness. The nursing diagnosis “Risk for injury, related to adverse effect of the drug” directly addresses this critical issue, making it the priority in this situation.
Choice D rationale
This choice is incorrect. Noncompliance due to the cost of the drug is an important consideration, but it does not address the immediate safety risk posed by sedation. The priority should be to ensure the patient’s safety by managing the side effects that could lead to injury. Cost-related concerns can be addressed after ensuring that the patient is not at immediate risk of harm. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Magnesium plays a role in various cellular functions, including enzyme activity and muscle contraction, but it does not directly inactivate troponin to enable actin and myosin interaction.
Choice B rationale
Sodium is essential for action potential generation and nerve impulse transmission but does not directly influence troponin activity or muscle contraction through actin and myosin bridge formation.
Choice C rationale
Potassium is critical for maintaining cellular resting membrane potential and repolarization of cells but does not play a direct role in inactivating troponin to facilitate muscle contraction.
Choice D rationale
Calcium is the electrolyte that inactivates troponin, allowing actin and myosin to form cross-bridges and contract muscle fibers. Calcium binds to troponin, causing a conformational change that exposes binding sites for myosin on actin filaments.
Correct Answer is A
Explanation
Choice A rationale
CSF analysis and MRI are crucial in diagnosing multiple sclerosis (MS). CSF may show elevated levels of oligoclonal bands, indicative of immune system activity in the central nervous system. MRI can detect lesions or plaques in the brain and spinal cord, which are characteristic of MS.
Choice B rationale
Serum albumin and CT scan are not standard diagnostic tools for MS. Serum albumin is more relevant to liver function and nutritional status, while CT scans are less sensitive than MRIs in detecting MS lesions.
Choice C rationale
CSF proteins and angiography are not standard tests for diagnosing MS. While CSF protein levels might be altered in MS, angiography is used to visualize blood vessels and is not relevant to MS diagnosis.
Choice D rationale
Serum anti-acetylcholine antibodies and x-rays are not used to diagnose MS. Anti-acetylcholine antibodies are related to myasthenia gravis, and x-rays are not useful for visualizing MS lesions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.