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A nurse is caring for a client who is postoperative following administration of general anesthesia.

Exhibits

Select from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition Most Likely Experiencing: Malignant Hyperthermia

The client's tachycardia (HR 134/min), tachypnea (RR 28/min), hypotension (BP 92/52 mm Hg), and hypoxia (SpO₂ 89%) are key signs of malignant hyperthermia (MH), a life-threatening reaction to general anesthesia.
While hyperthermia (elevated temperature) is a late sign, the presence of early indicators like tachycardia, tachypnea, and hypoxia strongly suggests MH.
Incorrect choices:
- Paralytic ileus (A): This is a possible secondary complication but not the primary issue.
- Nausea and vomiting (B): Common post-op symptoms, but they don’t explain the severe vitals.
- Hypercapnia (C): The client is hyperventilating, not hypoventilating.
- Latex allergy (E): No signs of urticaria, anaphylaxis, or bronchospasm, which would indicate a latex allergy.

Correct Answer: Malignant hyperthermia

Two Actions to Take:

Administer dantrolene (C)
- Dantrolene is the only effective antidote for MH. It directly relaxes skeletal muscles and stops the uncontrolled muscle metabolism that drives the crisis.
Monitor muscle rigidity (E)
- Muscle rigidity is a hallmark sign of MH, especially in the jaw and upper body. The nurse must monitor for worsening rigidity as an indicator of disease progression.

Incorrect choices:
- Obtain the latex-free cart (A): There is no indication of a latex allergy.
- Administer ondansetron (B): Useful for nausea and vomiting but does not address MH.
- Insert an NG tube (D): Might be needed for paralytic ileus but is not a priority in treating MH.

Correct Answers: Administer dantrolene, Monitor muscle rigidity

Two Parameters to Monitor:

Bowel sounds (C)
- Paralytic ileus can develop as a secondary complication of MH due to decreased blood flow to the intestines during the crisis. Monitoring bowel sounds helps detect this issue early.
Muscle rigidity (E)
- Since sustained muscle contractions are a key feature of MH, tracking muscle rigidity helps assess whether the crisis is worsening or improving.

Incorrect choices:
- Blood pressure (A): While important, it is not a specific marker for MH progression.
- Urine output (B): Useful for assessing kidney function but not directly related to MH management.
- Skin integrity (D): Not a priority in this emergency.

Correct Answers: Bowel sounds, Muscle rigidity

Summary of Correct Answers:

Condition Most Likely Experiencing: Malignant hyperthermia
Two Actions to Take: Administer dantrolene, Monitor muscle rigidity
Two Parameters to Monitor: Bowel sounds, Muscle rigidity

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Divalproex is an anticonvulsant and is not indicated for the treatment of acute dystonic reactions.
B. IV isotonic crystalloid fluid is used for hydration but is not the primary treatment for dystonic reactions.
C. Lorazepam is a benzodiazepine, which may be used for anxiety or seizure activity, but is not effective for managing dystonic reactions.
D. Benztropine is an anticholinergic medication used to treat acute dystonic reactions, including those causing laryngeal spasms. It works by reducing the excessive cholinergic activity that leads to these symptoms.

A. Determine how the client is administering the medication. B. Advise the client to gargle with warm salt water twice daily. C. Report the client's jaw pain to the healthcare provider. D. Confirm that this is a common symptom of osteoporosis.

Correct Answer is C

Explanation

A. Determine how the client is administering the medication: While the nurse should assess medication administration, jaw pain could be a sign of a serious side effect, and reporting to the healthcare provider is the priority.
B. Advise the client to gargle with warm salt water twice daily: Gargling with salt water may provide some comfort but is not an appropriate solution for jaw pain related to bisphosphonate therapy.
C. Report the client's jaw pain to the healthcare provider: Jaw pain could be a sign of osteonecrosis of the jaw, a rare but serious side effect of bisphosphonates. Immediate reporting is essential.
D. Confirm that this is a common symptom of osteoporosis: Jaw pain is not a common symptom of osteoporosis and should be assessed further.

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Summary of Correct Answers:

Nursing Test Bank

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A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is D

Explanation

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Correct Answer is C

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