A nurse is caring for a 45-year-old male client in a provider’s clinic.
Select all that apply. Which of the following findings require follow-up by the nurse?
Report of fluid intake
Gastrointestinal findings
Muscle movement findings
Vital signs
Urine output
Correct Answer : B,C,D,E
Choice A rationale: Fluid intake is essential for maintaining hydration and overall health, especially for clients with bipolar disorder. However, it is not the most immediate concern unless specific signs of dehydration or other related issues are noted.
Choice B rationale: Gastrointestinal findings require follow-up because medication changes can cause nausea, vomiting, or other gastrointestinal disturbances. These symptoms can affect the client's nutrition and overall well-being, particularly with new medications in bipolar disorder management.
Choice C rationale: Muscle movement findings such as tremors, stiffness, or involuntary movements should be monitored. These can indicate side effects of psychiatric medications, including extrapyramidal symptoms or tardive dyskinesia, which require immediate medical evaluation.
Choice D rationale: Vital signs are crucial to monitor because abnormal readings can indicate adverse effects of medication. For example, certain medications used in bipolar disorder management can affect heart rate and blood pressure, which need regular assessment.
Choice E rationale: Urine output is important to track because changes in renal function can occur with certain medications. Monitoring for any alterations in urine output helps assess potential nephrotoxicity or other renal issues, which are critical for client health.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Magnesium level of 2.5 mEq/L is slightly above the normal range (1.3 to 2.1 mEq/L) but does not necessitate discontinuation of clozapine, as it does not indicate a serious adverse effect.
Choice B rationale
Potassium level of 5.4 mEq/L is marginally elevated above the normal range (3.5 to 5 mEq/L) but is not a critical concern for discontinuing clozapine, which is more closely monitored for hematologic effects.
Choice C rationale
A WBC count of 2,500/mm³ is significantly below the normal range (5,000 to 10,000/mm³). Clozapine can cause agranulocytosis, a severe decrease in white blood cells, necessitating immediate discontinuation.
Choice D rationale
Sodium level of 134 mEq/L is slightly below the normal range (136 to 145 mEq/L) but does not require discontinuation of clozapine. This mild hyponatremia can be monitored and managed without stopping the medication.
Correct Answer is D
Explanation
Choice A rationale
Respiratory rate of 24/min indicates possible respiratory distress but is not a common adverse effect of propranolol, which typically affects heart rate and blood pressure.
Choice B rationale
An oral temperature of 38.9° C (102°F) suggests fever, which is not a known adverse effect of propranolol. Common side effects are bradycardia, hypotension, and fatigue.
Choice C rationale
Blood pressure of 118/78 mm Hg is within normal range (90/60 to 120/80 mm Hg) and is not an adverse effect of propranolol, which usually lowers blood pressure.
Choice D rationale
Apical pulse of 50/min indicates bradycardia, a common adverse effect of propranolol, which reduces heart rate by blocking beta-adrenergic receptors.
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