A nurse admits an older patient to the emergency room with reports of shortness of breath on exertion and a productive cough.
The nurse reviews the patient's current medications and the patient says, “I take one pink pill every morning.”. The nurse asks the name of the drug and the patient says she doesn’t know.
The patient cannot supply the name of the drug or the purpose of taking it either.
This happens with four other medications the patient says she takes.
What is an appropriate nursing diagnosis for this patient?
Ineffective health maintenance.
Noncompliance.
Acute confusion.
Risk-prone health behavior.
The Correct Answer is A
Choice A rationale
Ineffective health maintenance is appropriate due to the patient's inability to provide names and purposes of medications, indicating insufficient knowledge of their regimen.
Choice B rationale
Noncompliance implies intentional refusal of medication, which is not evident here as the patient is unaware rather than refusing.
Choice C rationale
Acute confusion is not indicated as the patient appears oriented and not disoriented.
Choice D rationale
Risk-prone health behavior is not appropriate as it suggests engagement in harmful activities, which is not described.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Myasthenia gravis is an autoimmune neuromuscular disorder characterized by weakness and fatigue of the skeletal muscles. Improvement of ptosis after administration of edrophonium (Tensilon), a short-acting acetylcholinesterase inhibitor, is a diagnostic indicator of myasthenia gravis.
Choice B rationale
Cerebral palsy is a group of permanent movement disorders that appear in early childhood. It is primarily caused by abnormal development or damage to the brain and does not exhibit rapid improvement with edrophonium.
Choice C rationale
Multiple sclerosis is a chronic illness involving the central nervous system, where the immune system attacks the protective sheath (myelin) that covers nerve fibers. It does not respond to edrophonium as myasthenia gravis does.
Choice D rationale
Muscle spasm refers to an involuntary contraction of a muscle that can be sudden and painful. This condition is not typically diagnosed or treated with edrophonium, which is specific for myasthenia gravis. .
Correct Answer is A
Explanation
Choice A rationale
Oral morphine typically reaches peak activity at around 45 minutes after administration. This allows time for the medication to be absorbed through the gastrointestinal tract and enter the bloodstream to provide pain relief.
Choice B rationale
10 minutes is too short for oral morphine to reach peak activity. This timeframe is more consistent with intravenous administration, which allows for rapid onset of action.
Choice C rationale
30 minutes is a bit too short for oral morphine to reach peak effect, although some patients may start to feel relief. However, peak plasma concentrations generally occur closer to 45-60 minutes.
Choice D rationale
While morphine can continue to have effects up to 60 minutes and beyond, the peak activity is typically observed around the 45-minute mark. Waiting for 60 minutes may underestimate the peak timeframe.
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