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 B
Explanation
Choice A rationale
Beta-adrenergic blockers generally do not decrease urinary output. These drugs primarily act on the cardiovascular system by blocking beta-adrenergic receptors, which results in lowered heart rate and blood pressure. Their effects are less pronounced on the renal system unless specific agents with renal effects are used.
Choice B rationale
Beta-adrenergic blockers decrease the strength of heart muscle contraction (negative inotropic effect). By blocking beta receptors, they inhibit the stimulatory effects of catecholamines on the heart, reducing the force of myocardial contraction, which helps decrease oxygen demand and control angina symptoms.
Choice C rationale
Beta-adrenergic blockers typically decrease heart rate (negative chronotropic effect) rather than increase it. They inhibit beta-adrenergic receptors, which leads to a slower heart rate and can help manage conditions like angina by reducing myocardial oxygen consumption.
Choice D rationale
Beta-adrenergic blockers decrease oxygen consumption by reducing heart rate and the force of contraction. These effects lower myocardial oxygen demand, which is beneficial for patients with angina by preventing episodes triggered by increased oxygen needs.
Correct Answer is C
Explanation
Choice A rationale
Checking vitamin K levels doesn't directly monitor warfarin's effect.
Choice B rationale
PTT and aPTT assess heparin, not warfarin.
Choice C rationale
INR specifically measures warfarin's effectiveness and safety.
Choice D rationale
Platelet levels don't monitor the anticoagulant effect of warfarin.
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