A nurse is collecting data from a client who has been taking medroxyprogesterone for 6 months. Which of the following statements by the client should the nurse identify as the priority to report?

I have occasional vaginal spotting."

I have developed brown patches on my face."

I have breast tenderness."

I have intermittent calf pain."

Answer and Explanation

The Correct Answer is D

A) I have occasional vaginal spotting: Vaginal spotting can occur as a side effect of medroxyprogesterone, especially in the first few months of use. While this should be monitored, it is not an immediate concern that requires urgent reporting unless the spotting becomes heavy or persistent, which could indicate other issues.

B) I have developed brown patches on my face: The development of brown patches on the face (known as melasma) is a known side effect of hormonal contraceptives, including medroxyprogesterone. Although this is an undesirable cosmetic effect, it is not an urgent medical concern that requires immediate attention.

C) I have breast tenderness: Breast tenderness is a common side effect of medroxyprogesterone and other hormonal medications. It is usually mild and resolves over time. While the client should continue to monitor the tenderness, it does not present an immediate risk or require urgent intervention.

D) I have intermittent calf pain: Intermittent calf pain could be a sign of a more serious complication, such as a deep vein thrombosis (DVT), especially since medroxyprogesterone can increase the risk of blood clots. This symptom should be reported immediately to the healthcare provider, as a DVT could potentially lead to a pulmonary embolism if left untreated, which is a life-threatening condition. Therefore, this is the priority finding to report.

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Correct Answer is B

Explanation

A) Social withdrawal: While social withdrawal can be a sign of depression or a worsening cognitive decline in clients with Alzheimer's disease, it does not immediately threaten the client's safety. It is important to monitor and address, but it is not the priority concern that requires immediate intervention.

B) Wandering outside at night: This is the priority issue and requires immediate intervention. Wandering, especially at night, poses a significant safety risk to clients with Alzheimer's disease. The client may become lost, disoriented, or fall, leading to injury. Immediate steps should be taken to ensure the environment is safe, such as installing locks or alarms on doors, and potentially seeking further evaluation or care interventions to manage this behavior.

C) Difficulty articulating words: Difficulty with speech or articulation can occur as part of Alzheimer's disease, especially in the later stages. While it can be distressing for the client and family, it does not present an immediate threat to the client's safety. This issue should be addressed as part of the overall care plan, but it is not as urgent as wandering.

D) Inability to remember their partner's name: Memory loss, including difficulty remembering names, is a common symptom of Alzheimer's disease. While it can be emotionally difficult for both the client and their family, it does not pose an immediate risk to the client’s safety or well-being. This symptom should be monitored, but it is not the top priority for immediate intervention.

Correct Answer is ["30"]

Explanation

To calculate the drip rate, follow these steps:

The client needs to receive 120 mL of lactated Ringer's over 1 hour (60 minutes).
The IV tubing has a drip factor of 15 drops per mL (15 gtt/mL).
Multiply the total volume (120 mL) by the drip factor (15 gtt/mL), which gives 1,800 drops.
Divide this by the total time in minutes (60 minutes).

1,800 drops ÷ 60 minutes = 30 drops per minute (30 gtt/min)

Final Answer:

30 gtt/min

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A nurse is collecting data from a client who has been taking medroxyprogesterone for 6 months. Which of the following statements by the client should the nurse identify as the priority to report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from the family members of a client who has Alzheimer's disease. Which of the following findings should the nurse identify is the priority and requires immediate intervention?

Correct Answer is B

Explanation

Correct Answer is ["30"]

Explanation

Final Answer:

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