A nurse is making a follow-up call to client who has a new prescription for ACE inhibitor to treat hypertension. The client reports lightheadedness upon standing. Which of the following statements should the nurse make?
*Restrict your daily fluid intake."
*Take a daily potassium supplement."
*Discontinue this medication if this occurs again."
"Sit back down for a few minutes when this occurs."
The Correct Answer is D
A) *Restrict your daily fluid intake: Restricting fluid intake is not recommended for a client experiencing lightheadedness upon standing, especially when taking an ACE inhibitor. In fact, maintaining adequate hydration is important to help prevent hypotension, which could be exacerbated by fluid restriction. The lightheadedness may be due to orthostatic hypotension, which is a common side effect of ACE inhibitors.
B) *Take a daily potassium supplement: ACE inhibitors can increase potassium levels in the blood, potentially leading to hyperkalemia. For most clients, taking a potassium supplement is not necessary unless specified by the healthcare provider. In fact, many clients taking ACE inhibitors need to avoid excessive potassium intake, unless directed otherwise, to prevent dangerous potassium levels.
C) *Discontinue this medication if this occurs again: The nurse should not advise the client to discontinue the medication without consulting the healthcare provider. Lightheadedness upon standing is a common side effect of ACE inhibitors due to their blood pressure-lowering effects, and the healthcare provider should be notified if this becomes problematic. The decision to change or discontinue the medication should be made by the provider.
D) "Sit back down for a few minutes when this occurs": This is the most appropriate advice. Lightheadedness upon standing can be a sign of orthostatic hypotension, which is a known side effect of ACE inhibitors. The client should be instructed to sit down and rest when they experience these symptoms. If necessary, they should stand up slowly to allow their body to adjust to changes in position, which can help alleviate the lightheadedness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Patient Health Questionnaire - 9:
The Patient Health Questionnaire-9 (PHQ-9) is a screening tool used to assess the severity of depression in a client. It is not specific to detecting tardive dyskinesia, which is a movement disorder caused by long-term use of antipsychotic medications. Therefore, this tool is not appropriate for assessing tardive dyskinesia.
B) Abnormal Involuntary Movement Scale:
The Abnormal Involuntary Movement Scale (AIMS) is the correct tool to screen for tardive dyskinesia. It is specifically designed to assess involuntary movements, such as those seen in tardive dyskinesia, which is a common side effect of long-term use of antipsychotic medications. The AIMS evaluates the presence and severity of abnormal movements, making it the most appropriate tool for this purpose.
C) Mental Status Examination:
The Mental Status Examination (MSE) is a broad assessment used to evaluate a client’s cognitive and emotional functioning. It includes aspects such as appearance, behavior, mood, thoughts, and perception but does not specifically assess for movement disorders like tardive dyskinesia. While it can provide useful information about a client's mental state, it is not focused on detecting motor side effects of antipsychotic medications.
D) Brief Psychiatric Rating Scale:
The Brief Psychiatric Rating Scale (BPRS) is used to assess the severity of psychiatric symptoms, including delusions, hallucinations, and mood disturbances, primarily in individuals with schizophrenia or other psychiatric disorders. It does not specifically assess for tardive dyskinesia, so it is not the most appropriate screening tool for identifying this condition.
Correct Answer is B
Explanation
A) Prolonged PT/INR:
A prolonged PT/INR is typically associated with liver dysfunction or clotting disorders. While pancreatitis can lead to complications like bleeding, it does not directly cause a prolonged PT/INR. In the case of pancreatitis, the main concerns are related to enzymes, fluid and electrolyte imbalances, and potential organ dysfunction, but clotting issues are not a primary diagnostic feature.
B) Elevated lipase:
This is the most characteristic lab finding in pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly when the pancreas is inflamed. Elevated lipase levels are a key diagnostic indicator of pancreatitis, often seen alongside elevated amylase levels. This finding helps confirm the diagnosis and monitor the severity of the condition.
C) Decreased albumin:
Decreased albumin levels are typically seen in conditions that affect liver function, kidney disease, or malnutrition. While pancreatitis can lead to some degree of malnutrition or fluid shifts, a decreased albumin level is not a specific or expected finding in pancreatitis itself. The focus is more on enzyme levels and possible complications like hypocalcemia or hyperglycemia.
D) Elevated ammonia:
Elevated ammonia levels are generally indicative of liver dysfunction or hepatic encephalopathy, which occurs in severe liver disease. While pancreatitis can cause systemic complications, an elevated ammonia level is not a typical lab finding associated with pancreatitis. Ammonia is more commonly monitored in cases of liver failure or cirrhosis.
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