A nurse is caring for a client who is receiving prazosin. The client's blood pressure is 100/60 mm Hg. Which of the following actions should the nurse take?
Administer a reversal agent
Initiate cardiac monitoring
Instruct the client to stand up slowly.
Inform the client to report urinary retention
The Correct Answer is C
c. Instruct the client to stand up slowly.
Explanation:
The correct answer is c. Instruct the client to stand up slowly.
Prazosin is an alpha-1 adrenergic blocker used to treat hypertension and benign prostatic hyperplasia. One of the common side effects of prazosin is orthostatic hypotension, which can cause a drop in blood pressure when changing positions from lying or sitting to standing.
In this scenario, the client's blood pressure is 100/60 mm Hg, which indicates hypotension. To prevent a sudden drop in blood pressure and related symptoms such as dizziness or fainting, the nurse should instruct the client to stand up slowly. This allows the body time to adjust to the change in position and minimizes the risk of orthostatic hypotension.
Option a, administering a reversal agent, is not necessary in this situation. Reversal agents are used to counteract the effects of specific medications when there is a need to rapidly reverse their actions. There is no indication in the scenario that the client requires a reversal agent.
Option b, initiating cardiac monitoring, is not warranted based solely on a blood pressure reading of 100/60 mm Hg. Cardiac monitoring is typically indicated when there are specific cardiac concerns or symptoms, which are not mentioned in the scenario.
Option d, informing the client to report urinary retention, is a potential side effect of prazosin but is not the most appropriate action to take in this situation. The client's blood pressure is the immediate concern, and addressing orthostatic hypotension by instructing the client to stand up slowly is the appropriate action.
By instructing the client to stand up slowly, the nurse promotes safety and minimizes the risk of orthostatic hypotension, allowing the client to adjust to the change in position and reduce the likelihood of experiencing symptoms related to low blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. "You feel upset by the responses of others."
The appropriate response by the nurse is to acknowledge and validate the client's feelings. Option b, "You feel upset by the responses of others," demonstrates empathy and reflects back the client's feelings, indicating that the nurse understands and acknowledges the client's distress.
Explanation for the other options:
a. "I think you should just ignore the others." This response dismisses the client's concerns and does not address the underlying issue of the client feeling hurt by the interactions with others. It is important for the nurse to address the client's feelings and provide support.
c. "Let's keep the focus of our discussion on your needs." While it is important to address the client's needs, it is also necessary to address the client's concerns and feelings related to the interactions with other clients. Ignoring or dismissing the client's concerns can further isolate the client and hinder their progress in the therapeutic environment.
d. "Everything will get beter once you get to know everyone." This response minimizes the client's feelings and does not provide immediate support or address the client's concerns. It is essential for the nurse to validate the client's emotions and explore strategies to address the issue of others making fun of the client.
In summary, the nurse should choose a response that acknowledges the client's feelings and demonstrates empathy. Validating the client's experience can help establish trust and provide a foundation for further therapeutic interventions.
Correct Answer is D
Explanation
When a client with active pulmonary tuberculosis (TB) receives appropriate treatment and their sputum cultures consistently show negative results for Mycobacterium tuberculosis, it indicates that the client is no longer contagious. Negative sputum cultures indicate that the infectious bacteria are no longer present or viable in the respiratory secretions, reducing the risk of transmitting the disease to others.
"You will need an annual TB skin test to see if the infection has returned": While it is important for individuals with a history of TB to undergo periodic screening, such as an annual TB skin test or interferon-gamma release assay (IGRA), to detect latent TB infection or potential reactivation, this response is not specifically related to a client with active pulmonary TB.
"You will take medication to treat your illness for the rest of your life": This response is incorrect because active pulmonary TB is typically treated with a combination of antimicrobial medications for a specific duration, usually ranging from 6 to 9 months. It is not a lifelong treatment.
However, individuals with latent TB infection may require longer-term treatment to prevent the development of active TB disease.
"You can expect the medications to turn your urine a blue-green color": This response is incorrect as medications used to treat TB do not typically cause urine discoloration. Medications such as rifampin can cause various side effects, including orange discoloration of bodily fluids like urine, tears, or sweat, but a blue-green color is not associated with TB medications.
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