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A nurse is assisting in the care of a female client.

Complete the following sentence by using the lists of options.

The nurse should first address the client

followed by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

  • Blood pressure. The client's blood pressure dropped from 104/56 mm Hg to 80/46 mm Hg, indicating worsening hypotension. This suggests fluid volume depletion due to ongoing diarrhea and possible sepsis from Clostridium difficile infection. Hypotension is the priority concern as it can lead to shock and organ dysfunction if not addressed immediately. The nurse should anticipate fluid resuscitation with IV fluids to restore circulatory volume.
  • Hgb level. The client's hemoglobin is 17 g/dL, which is elevated compared to normal values (12-16 g/dL). This suggests hemoconcentration, likely due to dehydration from severe diarrhea rather than an actual increase in red blood cell count. While this is concerning, the immediate priority is addressing hypotension before evaluating hemoglobin further.
  • Temperature. The client has a persistent fever of 38.9°C (102°F), which indicates an active Clostridium difficile infection. While fever management is important, hypotension takes priority because it can lead to hypoperfusion and organ failure. Antipyretic medications and infection control measures can be initiated after stabilizing blood pressure.
  • Potassium level. The client's potassium is 3.1 mEq/L, which is below the normal range (3.5-5.0 mEq/L). Diarrhea leads to potassium loss, increasing the risk of cardiac arrhythmias and muscle weakness. After stabilizing the client’s blood pressure, potassium replacement is critical to prevent life-threatening hypokalemia-related complications such as cardiac dysrhythmias.
  • Abdominal findings. The client has a soft, distended abdomen with hyperactive bowel sounds and watery stools with mucus, consistent with Clostridium difficile infection. While these findings confirm the diagnosis, the more urgent issues of hypotension and electrolyte imbalances must be addressed first before further gastrointestinal assessment.
  • Hct level. The hematocrit is elevated (48%), which aligns with hemoconcentration from dehydration. However, fluid resuscitation will help correct this, making it a secondary concern after addressing blood pressure and potassium levels.


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Related Questions

Correct Answer is A

Explanation

A. Drowsiness. Dimenhydrinate is an antihistamine that works by blocking histamine and acetylcholine receptors in the brain to prevent nausea and vomiting. A common adverse effect is drowsiness due to its sedative properties, which can impair alertness and coordination. Clients should be advised to avoid activities requiring mental alertness, such as driving, until they understand how the medication affects them.

B. Hypertension. Dimenhydrinate does not typically cause hypertension. Instead, it may lead to mild hypotension due to its sedative and anticholinergic effects. Clients with pre-existing hypertension should still monitor their blood pressure, but significant increases are uncommon.

C. Polyuria. Increased urination is not associated with dimenhydrinate use. Antihistamines, including dimenhydrinate, have anticholinergic properties, which can lead to urinary retention rather than increased urine output. Clients experiencing difficulty urinating should report this to their healthcare provider.

D. Dependent edema. Dimenhydrinate does not cause fluid retention or edema. Medications that contribute to edema typically involve hormonal, cardiovascular, or kidney-related effects, which are not mechanisms of dimenhydrinate. If a client develops unexplained edema, other underlying conditions should be investigated.

Correct Answer is B

Explanation

A. Tinnitus. Phenytoin is not commonly associated with tinnitus. Ototoxicity is more frequently linked to medications such as aminoglycoside antibiotics, loop diuretics, or high-dose aspirin. While phenytoin affects the nervous system, it does not typically cause ringing in the ears.

B. Bleeding gums. Gingival hyperplasia, characterized by swollen and bleeding gums, is a well-known adverse effect of phenytoin, especially with long-term use. It occurs due to an overgrowth of gum tissue and can be minimized with good oral hygiene and regular dental care. Clients should be advised to brush with a soft-bristled toothbrush and visit the dentist regularly.

C. Jaundice. Although phenytoin is metabolized by the liver, hepatotoxicity and jaundice are not common side effects. However, liver function should still be monitored, particularly in clients with pre-existing liver conditions or those taking other hepatotoxic medications.

D. Deep vein thrombosis. Phenytoin does not significantly increase the risk of deep vein thrombosis (DVT). While some anticonvulsants may affect coagulation factors, phenytoin is not known to cause hypercoagulability or clot formation. Clients at risk for DVT should be monitored for other contributing factors, such as immobility or genetic predisposition.

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