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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 B

Explanation

A. Hypoglycemia. Neither spironolactone nor lisinopril directly affects blood glucose levels. Hypoglycemia is more commonly associated with insulin, sulfonylureas (e.g., glipizide), and excessive alcohol consumption, rather than potassium-sparing diuretics or ACE inhibitors.

B. Hyperkalemia. Spironolactone is a potassium-sparing diuretic that promotes sodium excretion while retaining potassium, increasing the risk of hyperkalemia. Lisinopril, an ACE inhibitor, also raises potassium levels by reducing aldosterone secretion, which normally promotes potassium excretion. The combination of these two medications significantly increases the risk of dangerously high potassium levels, which can lead to cardiac arrhythmias, muscle weakness, and life-threatening complications. Clients should have serum potassium levels monitored regularly and be advised to avoid potassium-rich foods and supplements.

C. Hyperglycemia. Neither medication is known to cause hyperglycemia. Thiazide and loop diuretics are more likely to elevate blood glucose levels due to their effects on insulin sensitivity, but spironolactone and lisinopril do not share this effect.

D. Hypokalemia. Spironolactone prevents potassium loss, and lisinopril reduces potassium excretion, making hypokalemia unlikely. Hypokalemia is more commonly seen with loop diuretics (e.g., furosemide) and thiazide diuretics (e.g., hydrochlorothiazide), which promote potassium loss.

Correct Answer is B

Explanation

A. Varenicline. Varenicline is used to aid smoking cessation by reducing nicotine cravings and withdrawal symptoms. It does not have a role in managing acute alcohol withdrawal and would not be effective in preventing withdrawal-related complications.

B. Diazepam. Diazepam, a benzodiazepine, is commonly used to manage acute alcohol withdrawal by preventing seizures, reducing agitation, and alleviating autonomic hyperactivity (e.g., tachycardia, hypertension). It enhances GABA activity, which helps counteract the excitatory effects of alcohol withdrawal, reducing the risk of delirium tremens (DTs).

C. Clonidine. Clonidine is an alpha-2 agonist that helps control autonomic symptoms such as elevated blood pressure and heart rate. While it may be used as an adjunct therapy, it does not prevent seizures or delirium, making it insufficient as a primary treatment for alcohol withdrawal.

D. Methadone. Methadone is used for opioid withdrawal and maintenance therapy in opioid dependence. It does not alleviate alcohol withdrawal symptoms or prevent complications such as seizures or delirium, making it inappropriate for this condition.

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