A nurse is caring for an adolescent client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
Request a dietitian consult
Request an order for an antiemetic.
Check the client's vital signs.
Suggest that the client rests before eating the meal.
The Correct Answer is C
A. A dietitian consult can be considered, but it is not the priority.
B. Requesting an antiemetic may be helpful for nausea but does not address the underlying cause.
C. Checking vital signs is the priority as nausea and weakness can indicate digoxin toxicity, which can cause cardiac complications.
D. Resting before eating does not address the potential for toxicity and other complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Children with Down syndrome often experience developmental delays, and explaining this helps reassure the parent.
B. While a physical therapist may be helpful, the nurse should first address the parent's concerns with information.
C. Asking about siblings does not address the parent's specific concern.
D. Asking about other milestones may shift focus away from the parent's immediate worry.
Correct Answer is A
Explanation
A. Preferring friends over family can be typical of adolescent development and does not necessarily indicate depression. This suggests the parent may need further education about distinguishing normal adolescent behavior from depression.
B. Significant weight changes can indicate depression in adolescents and should be monitored.
C. Increased sleep can be a symptom of depression in adolescents.
D. Poor academic performance is a possible sign of depression, as it may reflect loss of interest or concentration issues.
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