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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Educating the client on the consequences of not taking valproic acid is important for informed decision-making. Without the medication, seizure control may be compromised, leading to potential health risks.
Choice B rationale
Taking valproic acid with food can help minimize gastrointestinal side effects such as nausea by reducing gastric irritation and improving drug absorption.
Choice C rationale
Documenting the client's refusal in the medication administration record ensures accurate medical records and provides information for future healthcare decisions and assessments.
Choice D rationale
Enteric-coated formulations of valproic acid can reduce gastrointestinal irritation by allowing the drug to pass through the stomach and dissolve in the intestine.
Correct Answer is B
Explanation
Choice A rationale
Lorazepam is a benzodiazepine that acts on the central nervous system to produce sedative and anxiolytic effects, not directly affecting bladder function or urinary retention.
Choice B rationale
Bethanechol is a cholinergic agonist that stimulates the bladder's smooth muscle contraction, facilitating urination and relieving urinary retention. Normal bladder capacity is 400-600 mL.
Choice C rationale
Atropine is an anticholinergic drug that inhibits bladder contraction, worsening urinary retention by relaxing bladder smooth muscle and increasing sphincter tone.
Choice D rationale
Furosemide is a loop diuretic that increases urine production by inhibiting sodium and chloride reabsorption in the kidneys, not directly addressing urinary retention.
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