A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?

Protruding hemorrhoids

3+deep-tendon reflexes

Supine hypotension

Urinary frequency

Answer and Explanation

The Correct Answer is B

A. Protruding hemorrhoids: Hemorrhoids are common in late pregnancy due to increased venous pressure and straining, and while uncomfortable, they are not an urgent concern requiring immediate provider notification.

B. 3+ deep-tendon reflexes: Hyperactive reflexes (3+) can indicate potential preeclampsia, which is a serious condition characterized by hypertension and risk of seizures. This finding requires prompt reporting and further evaluation to prevent complications for both the mother and fetus.

C. Supine hypotension: Supine hypotensive syndrome can occur when a pregnant client lies on her back, causing compression of the inferior vena cava. It is typically relieved by repositioning to the left lateral side and is not immediately dangerous if addressed promptly.

D. Urinary frequency: Increased urinary frequency is common in late pregnancy due to fetal pressure on the bladder. While it may cause discomfort, it is an expected finding and does not require urgent reporting to the provider.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

A. Headache: Disulfiram causes an aversive reaction when alcohol is consumed, leading to vasodilation and increased acetaldehyde levels. This often results in a severe, throbbing headache as one of the earliest and most common manifestations. The symptom appears quickly after alcohol intake and signals a disulfiram–alcohol interaction.

B. Vomiting: Accumulation of acetaldehyde triggers gastrointestinal distress, including nausea and profuse vomiting. These symptoms occur because the body is unable to metabolize alcohol properly while on disulfiram. Vomiting is a classic indicator that alcohol was consumed after starting therapy.

C. Confusion: Neurological effects such as confusion can develop during a disulfiram–alcohol reaction due to hypotension, decreased cerebral perfusion, and heightened toxin buildup. This change in mental status is especially concerning and suggests significant physiological stress after alcohol ingestion.

D. Sedation: Sedation is not a typical effect of a disulfiram–alcohol reaction. It is more commonly associated with other CNS depressants or alcohol intoxication alone. Because it does not reflect the vasodilatory or metabolic effects produced by disulfiram, it is not a reliable indicator of concurrent alcohol use.

E. Sweating: Sweating results from the sympathetic surge that occurs when acetaldehyde levels rise during a disulfiram–alcohol reaction. Clients may experience flushing, tachycardia, and diaphoresis as part of the acute response. This strongly supports that alcohol was consumed while taking disulfiram.

A. "This medication can cause nausea and drowsiness." B. "You will be placed on a low-sodium diet while taking this medication." C. "Blurred vision is an expected adverse effect of this medication." D. "This medication can cause weight gain." E. "It will take at least a week before this medication reachesa therapeutic level."

Correct Answer is ["A","D","E"]

Explanation

A. "This medication can cause nausea and drowsiness.": Gastrointestinal upset and central nervous system effects such as drowsiness are common early adverse effects of lithium therapy. Clients should be informed so they can recognize mild side effects versus signs of toxicity.

B. "You will be placed on a low-sodium diet while taking this medication.": Lithium requires a consistent, not low, sodium intake. Low sodium can increase lithium reabsorption in the kidneys, raising the risk of toxicity. Emphasizing a consistent dietary sodium intake is important rather than restricting sodium.

C. "Blurred vision is an expected adverse effect of this medication.": Blurred vision is not an expected side effect of lithium and may indicate toxicity or another ocular issue. Clients should report changes in vision promptly rather than consider them routine.

D. "This medication can cause weight gain.": Weight gain is a known side effect of lithium therapy due to fluid retention and metabolic changes. Clients and caregivers should be aware to monitor weight and maintain healthy lifestyle practices.

E. "It will take at least a week before this medication reaches a therapeutic level.": Lithium requires several days to reach a therapeutic blood level, and effects on mood stabilization are gradual. Educating the client about delayed onset helps set realistic expectations and encourages adherence.

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A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an outpatient clinic is caring for a client. Select the 4 findings that indicate the client has been consuming alcohol while taking the newly prescribed medication.

Correct Answer is ["A","B","C","E"]

Explanation

The nurse is continuing to care for the client. The nurse is providing teaching about lithium to the client and the client's adult child. Select the 3 statements the nurse should include.

Correct Answer is ["A","D","E"]

Explanation

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