A client who is admitted with an acute coronary syndrome (ACS) receives eptifibatide, a glycoprotein (GP) (IB IIIA. inhibitor. Which assessment finding places the client at greatest risk?
Unresponsive to painful stimuli.
Presence of hematemesis.
Incontinent with blood in urine.
Blood pressure of 100/60 mm Hg.
The Correct Answer is B
A. Unresponsiveness to painful stimuli indicates a potential neurological issue but does not directly correlate with the risk of bleeding associated with eptifibatide use.
B. Hematemesis indicates gastrointestinal bleeding, which is a significant concern in patients on eptifibatide, as it increases the risk of serious bleeding complications.
C. Blood in urine (hematuria) can indicate a urinary tract issue or bleeding but is less critical than gastrointestinal bleeding in this context.
D. A blood pressure of 100/60 mm Hg may indicate some degree of hypotension but is not as urgent as identifying active bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Anorexia Nervosa
The client's symptoms, such as low body weight (BMI of 16.8 kg/m²), bradycardia (HR of 48 bpm), hypothermia (temperature of 96.2°F), poor muscle tone, irregular menstruation, and the presence of lanugo, all strongly suggest anorexia nervosa. Additionally, the client's refusal to acknowledge weight loss and her distorted perception of body image further support this diagnosis.
Actions the Nurse Should Take:
Educate on the condition:
The nurse should educate the client and her family about the physical and psychological aspects of anorexia nervosa, including the risks of severe malnutrition, electrolyte imbalances, and long-term complications if not treated.
Acknowledge anxious feelings:
The nurse should validate the client’s anxious feelings about food and body image, providing emotional support and promoting a therapeutic relationship to encourage the client to engage in treatment.
Parameters to Monitor:
Weight:
Monitoring the client’s weight regularly is essential to assess nutritional progress and to detect any further weight loss or gains.
Achievement of 100% of ideal weight:
Assessing whether the client is progressing toward achieving a healthy weight (100% of ideal body weight) is a critical marker of recovery from anorexia nervosa.
Correct Answer is C
Explanation
A. This statement is incorrect; exercise can significantly affect blood glucose levels by improving insulin sensitivity and helping with glycemic control.
B. Soaking feet in hot water is not recommended as it can lead to burns or injuries, especially in individuals with reduced sensation.
C. Limiting alcoholic beverages to 1-2 per day is generally acceptable for most individuals with diabetes, as long as it is done cautiously and with food to prevent hypoglycemia.
D. While keeping wounds covered is important, simply using antibiotic ointment may not be sufficient, and proper wound care should be emphasized.
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