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 A
Explanation
Choice A rationale
This choice is correct. The side effects of paroxetine, including headaches, nervousness, and poor appetite, are common during the initial weeks of treatment and often decrease over time as the patient’s body adjusts to the medication. Reassuring the patient helps them continue the treatment without undue anxiety about these side effects, which are typically transient and manageable.
Choice B rationale
This choice is incorrect. Abruptly stopping paroxetine without consulting a healthcare provider is not recommended because it can lead to withdrawal symptoms and a possible relapse of depression or anxiety. The patient should only discontinue the medication under the guidance of a healthcare provider, who may suggest a gradual tapering off process to minimize withdrawal symptoms.
Choice C rationale
This choice is partially correct. Taking paroxetine with food can help mitigate some gastrointestinal side effects, such as nausea. However, it does not directly address headaches, nervousness, or poor appetite. Although taking the medication with food is a useful tip, it is not the most comprehensive advice for this particular situation.
Choice D rationale
This choice is incorrect. While adjusting the dose may be an option, it is premature to suggest this after only two weeks of treatment. The patient’s body may still be adjusting to the medication, and many side effects diminish with time. The decision to change the dosage should be made by the healthcare provider based on a thorough evaluation of the patient’s response to the treatment.
Correct Answer is D
Explanation
Choice A rationale
Deoxygenated blood from the lungs would not flow to the left atrium or through the pulmonary artery.
Choice B rationale
Deoxygenated blood from the lungs would not enter the right atrium or flow through the pulmonary artery.
Choice C rationale
Oxygenated blood from the lungs does not enter the right atrium through the pulmonary veins.
Choice D rationale
Correct, oxygenated blood from the lungs enters the left atrium through the pulmonary veins.
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