A client who has been taking colchicine calls the clinic with reports of an acute gout attack of the right great toe. The client has a history of kidney stones and esophageal reflux. Which finding warrants immediate intervention by the nurse?
Watery diarrhea.
Heart burn.
Confusion.
Hematuria.
The Correct Answer is C
Rationale:
A. Watery diarrhea: While a known side effect of colchicine toxicity, it is typically an early sign. It requires follow-up but is not the most urgent compared to neurological changes.
B. Heartburn: Esophageal irritation is a possible reaction due to colchicine's GI side effects, but this symptom is not immediately life-threatening.
C. Confusion: Neurological changes such as confusion may indicate severe colchicine toxicity or systemic complications like renal failure or CNS involvement, and warrant immediate evaluation.
D. Hematuria: Although significant in a patient with a history of kidney stones, hematuria is not the most urgent sign unless accompanied by flank pain, fever, or decreased output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Explanation
Rationale for Correct Choices:
- Frequent neurologic assessments: Frequent neurological checks are crucial during and after tPA administration to detect early signs of complications, particularly worsening neurological status, which may indicate intracranial bleeding. These assessments help ensure prompt intervention if deterioration occurs.
- Intracerebral hemorrhage: Intracerebral hemorrhage is the most serious and well-known risk of thrombolytic therapy. Monitoring for signs such as sudden headache, changes in consciousness, or worsening neurological symptoms is essential to detect this life-threatening complication early.
Rationale for Incorrect Choices:
- Continuous blood pressure monitoring: Although blood pressure control is important during tPA administration, continuous monitoring is not always required. Frequent checks (e.g., every 15 minutes) are typically sufficient unless there is an acute hypertensive crisis or rapid changes in neurological status.
- Hourly intake and output measuring: While intake and output may be monitored in ICU settings, this is not the priority during tPA administration. It does not help in detecting the most immediate and severe risk associated with thrombolytics.
- Pulmonary embolism: tPA is used to treat embolic events, not likely to cause them. Pulmonary embolism is not a known complication of thrombolytic therapy in ischemic stroke cases and would not be the primary concern during administration.
- Deep vein thrombosis: DVT is a potential complication from immobility in stroke patients, but not from tPA use. Monitoring for DVT is important during hospitalization but is not the priority during or immediately after tPA infusion.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
- Cortisol, epinephrine, and norepinephrine: These are key stress hormones activated during the fight-or-flight response. In PTSD, their persistent elevation is associated with symptoms like anxiety, agitation, and increased alertness, especially during perceived threats.
- Hypervigilance: Hypervigilance refers to an enhanced state of sensory sensitivity and constant scanning of the environment for threats. It is a hallmark of PTSD, evident in the client's easily startled behavior and environmental scanning.
Rationale for Incorrect Choices:
- Acetylcholine, epinephrine, and norepinephrine: Acetylcholine plays a greater role in attention and memory, not the stress response. Cortisol, not acetylcholine, is a more relevant hormone in PTSD-related hyperarousal and stress regulation.
- Dopamine, norepinephrine, and epinephrine: While dopamine influences motivation and pleasure, cortisol is more directly tied to the physiological stress response seen in PTSD. Omitting cortisol weakens the connection to stress-induced hyperalertness.
- Bradyphrenia: Bradyphrenia refers to slowed thinking, which is not typical in hyperaroused PTSD states. The client shows heightened awareness, not cognitive slowing.
- Hypoactivity: Hypoactivity implies reduced movement or response, which does not align with the client’s constant environmental scanning and heightened alertness. Hyperactivity, not hypoactivity, is more consistent with hypervigilance.
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