A nurse is assessing a client who takes diazepam for anxiety and hydromorphone for severe pain. Which of the following is the priority finding that the nurse should report to the provider?
Urinary retention
Blurred vision
Headache
Bradypnea
The Correct Answer is D
Choice A reason:
Urinary retention can be a side effect of both diazepam and hydromorphone, but it is not typically life-threatening. While it should be monitored and addressed, it is not the most urgent concern compared to respiratory issues.
Choice B reason:
Blurred vision can occur with the use of diazepam and hydromorphone, but it is generally not an immediate threat to the client’s life. It should be reported and managed, but it is not the highest priority.
Choice C reason:
Headache is a common side effect of many medications, including diazepam and hydromorphone. While it can be uncomfortable and may need treatment, it is not usually a sign of a life-threatening condition.
Choice D reason:
Bradypnea, or slow breathing, is a serious side effect that can occur with the use of both diazepam and hydromorphone, as both medications depress the central nervous system. This can lead to respiratory depression, which is potentially life-threatening and requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A reason:
Hallucinations, particularly if they are distressing or command hallucinations, can increase the risk of suicide attempts.
Choice B reason:
Depression is a major risk factor for suicide. Clients with a history of depression are at higher risk for attempting suicide again.
Choice C reason:
Delusions, especially those that are paranoid or persecutory, can contribute to suicidal thoughts and behaviors.
Choice D reason:
Catatonia, a state of psychomotor disturbance, can be associated with severe depression and increase the risk of suicide.
Choice E reason:
Tinnitus, while distressing, is not typically a direct risk factor for suicide attempts. It may contribute to overall distress but is not a primary indicator of suicide risk.
Correct Answer is B
Explanation
Choice A reason:
ECT is not contraindicated in clients with psychotic symptoms. In fact, it is often used to treat severe depression with psychotic features, as well as other conditions such as mania and catatonia. ECT can be highly effective in reducing symptoms of psychosis when other treatments have failed.
Choice B reason:
ECT is delivered through electrodes attached to the head. During the procedure, a small amount of electrical current is passed through the brain to induce a controlled seizure, which can help alleviate symptoms of severe depression and other mental health conditions.
Choice C reason:
ECT can be administered to clients with suicidal ideation. It is often considered when rapid symptom relief is needed, such as in cases of severe depression with a high risk of suicide. ECT can provide quick and significant improvement in mood and functioning.
Choice D reason:
ECT is conducted under general anesthesia, not regional anesthesia. General anesthesia ensures that the client is unconscious and does not feel pain during the procedure. Muscle relaxants are also administered to prevent physical convulsions during the induced seizure.
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