A male adult is admitted due to an overdose of acetaminophen.
After being transferred to the mental health unit, the patient is informed that he has liver damage.
What is the most crucial information for the nurse to include in the patient’s discharge plan?
Avoid exposure to large crowds.
Call the crisis hotline if feeling lonely.
Do not take any over-the-counter medications.
Follow a high carbohydrate, low fat, low protein diet.
The Correct Answer is C
Choice A rationale
While avoiding exposure to large crowds can help prevent infections, especially for patients with compromised immune systems, it is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Choice B rationale
While emotional support is important for patients dealing with health issues, calling a crisis hotline if feeling lonely is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Choice C rationale
This is the most crucial information for the patient. Acetaminophen is found in many over-the- counter medications, and further intake could exacerbate liver damage.
Choice D rationale
While a balanced diet is important for overall health, following a high carbohydrate, low fat, low protein diet is not the most crucial information for a patient with liver damage due to an overdose of acetaminophen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.
Correct Answer is A
Explanation
Choice A rationale
Given the client’s risk factors of poor wound healing, decreased bone density, and increased capillary fragility, the most appropriate outcome statement to include in the plan of care is that the client implements measures to prevent injury. This includes avoiding falls, using caution with sharp objects to prevent cuts, and taking steps to protect the bones.
Choice B rationale
While it is important for the client to understand their disease and ways to control it, this is not the most appropriate outcome statement given the client’s specific risk factors.
Choice C rationale
Improving body image may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Choice D rationale
Experiencing a normal fluid balance may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
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