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 B
Explanation
Rationale:
A. Aspiration: Aspiration is typically a concern in clients with impaired swallowing, reduced consciousness, or neurologic disorders. Elevated parathyroid hormone (PTH) does not directly affect swallowing function or airway protection.
B. Falls: Elevated PTH levels cause hypercalcemia, which can lead to muscle weakness, fatigue, confusion, and bone demineralization. These effects increase the client’s risk for falls and fractures, making fall prevention a key safety priority.
C. Suicide: While chronic illness can impact mood, elevated PTH levels are not directly associated with suicidal ideation. Psychiatric monitoring is important but not the primary safety focus in this case.
D. Hypothermia: PTH imbalance does not significantly affect thermoregulation. Hypothermia is not a typical complication of elevated PTH levels and does not require focused preventive measures in this scenario.
Correct Answer is B
Explanation
Rationale:
A. Recent change in the ability to read and drive after dark: This may indicate the onset of cataracts or age-related night vision decline, which is common in older adults. While it should be documented and followed up, it is not considered an urgent or emergent finding.
B. Gradual onset of continuous eye pain and blurred vision: This may suggest the development of angle-closure glaucoma or another serious ocular pathology, where increasing intraocular pressure could lead to permanent vision loss if not treated promptly.
C. Cloudy opacity of the crystalline lens: A cloudy lens is characteristic of cataracts, a common, non-urgent age-related change in older adults. Although it affects vision over time, it progresses slowly and can be addressed during routine follow-up care or elective surgery.
D. Gray-white circle around the iris of both eyes: This describes arcus senilis, a benign finding caused by lipid deposits in the corneal margin. It is common with aging and usually has no impact on vision or underlying pathology requiring urgent referral unless seen in younger adults.
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