A nurse is assessing a client who is receiving androgen therapy to treat endometriosis.
For which of the following adverse effects should the nurse monitor?
Weight loss.
Hypotension.
Muscle hypertrophy.
Edema.
The Correct Answer is D
Choice A rationale
Androgen therapy can lead to fluid retention, which would typically cause weight gain rather than weight loss. Androgens promote anabolism and can increase muscle mass and erythrocyte production, but they also influence fluid balance by affecting renal sodium and water reabsorption.
Choice B rationale
Androgen therapy generally does not cause hypotension. In some cases, it may lead to a slight increase in blood pressure due to fluid retention and effects on the renin-angiotensin-aldosterone system. Hypotension is not a recognized common adverse effect of androgen therapy.
Choice C rationale
Androgen therapy does promote muscle hypertrophy due to its anabolic effects, increasing protein synthesis and muscle mass. However, this is generally a desired therapeutic effect, not an adverse effect requiring monitoring for cessation, especially when used for conditions like muscle wasting.
Choice D rationale
Androgens can cause fluid retention, leading to edema. This occurs due to their influence on mineralocorticoid receptors in the renal tubules, which promotes sodium and water reabsorption. Nurses should monitor for signs of fluid overload, such as peripheral or pulmonary edema, and changes in body weight.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Morphine is a potent opioid analgesic commonly prescribed for moderate to severe pain. A dosage of 4 mg intravenously every four hours as needed for pain is within the typical therapeutic range for post-operative pain management, and the frequency allows for sufficient time between doses to assess the analgesic effect and minimize accumulation.
Choice B rationale
Hydromorphone is a very potent opioid, significantly stronger than morphine. A dosage of 2 mg intravenously every two hours for severe pain is a high dose and a relatively short interval. This combination increases the risk of opioid toxicity, including respiratory depression and profound sedation, necessitating verification with the prescribing provider.
Choice C rationale
Ondansetron is a serotonin receptor antagonist used to prevent and treat nausea and vomiting. A dosage of 4 mg orally every eight hours as needed for nausea is a standard and safe therapeutic dose, commonly employed in the post-operative setting to manage emesis with minimal adverse effects.
Choice D rationale
Docusate sodium is a stool softener that works by increasing water and fat penetration into the stool, making it easier to pass. A dosage of 240 mg orally daily as needed for constipation is a common and appropriate dose for preventing and managing post-operative constipation, which is a frequent side effect of opioid analgesics.
Correct Answer is D
Explanation
Choice A rationale
Administering aspirin for fever in a client receiving alteplase is contraindicated. Alteplase is a potent thrombolytic, and aspirin, an antiplatelet agent, would significantly increase the risk of bleeding. If fever is present, acetaminophen would be the preferred antipyretic due to its lack of antiplatelet activity, minimizing the risk of hemorrhage in this high-risk patient.
Choice B rationale
Ambulation is contraindicated in a client receiving thrombolytic therapy. Alteplase lyses existing clots, increasing the risk of bleeding, especially from sites of trauma or increased pressure. Maintaining bed rest and limiting movement helps to minimize the risk of hemorrhagic complications, such as hematoma formation or internal bleeding, which could be exacerbated by physical activity.
Choice C rationale
Administering a sodium phosphate enema is contraindicated in a client receiving thrombolytic therapy. Sodium phosphate enemas can cause rectal irritation, mucosal injury, and increased peristalsis, all of which elevate the risk of gastrointestinal bleeding in a patient whose coagulation cascade is already significantly impaired by alteplase. Stool softeners are preferred if constipation is present.
Choice D rationale
Monitoring for changes in the level of consciousness is a critical intervention for a client receiving alteplase. Intracranial hemorrhage is the most serious and life-threatening complication of thrombolytic therapy. Any alterations in neurological status, such as confusion, disorientation, or decreased responsiveness, could indicate intracranial bleeding and necessitate immediate intervention and discontinuation of the infusion.
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