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
Coagulation studies assess the blood's ability to clot and are not directly related to the monitoring of phenytoin therapy. These tests are more relevant for patients with bleeding disorders or those on anticoagulant therapy.
Choice B rationale
Serum electrolytes, including levels of sodium, potassium, and calcium, are important for overall health but are not specifically indicative of phenytoin levels. Phenytoin may affect calcium metabolism, but it is not the primary focus for routine monitoring.
Choice C rationale
Renal function tests are crucial for assessing kidney function but do not directly monitor phenytoin therapy. Phenytoin is primarily metabolized in the liver, making liver function tests more relevant.
Choice D rationale
Blood glucose levels should be monitored in patients taking phenytoin as the drug can cause alterations in blood glucose levels. Both hypoglycemia and hyperglycemia have been reported, so it is important to check glucose levels to ensure they remain within a normal range.
Correct Answer is D
Explanation
Choice A rationale
While a complete blood count (CBC) is an essential lab value for monitoring many conditions and potential side effects, it is not the primary concern when administering high doses of azithromycin, especially with co-administration of acetaminophen. The focus should be on liver function.
Choice B rationale
Urinalysis is useful in diagnosing and monitoring various conditions but is not directly relevant to monitoring the side effects of azithromycin and acetaminophen. These medications do not typically cause urinary abnormalities that would necessitate frequent urinalysis.
Choice C rationale
Electrolytes are not directly affected by azithromycin and acetaminophen use. Although monitoring electrolytes can be essential in broader contexts, these specific medications do not primarily impact electrolyte balance requiring focused monitoring.
Choice D rationale
Liver enzymes are the key lab values to monitor when administering high doses of azithromycin and acetaminophen. Both medications are metabolized by the liver and can cause hepatotoxicity. Monitoring liver enzymes helps in detecting early signs of liver damage and preventing further complications.
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.