A nurse is monitoring a client who took an overdose of acetaminophen 72 hr ago. The nurse should identify which of the following findings as a manifestation of acetaminophen poisoning?

Xerostomia

Constipation

Vomiting

Tinnitus

Answer and Explanation

The Correct Answer is C

A. Xerostomia: Dry mouth is not a typical manifestation of acetaminophen poisoning. It is more often associated with medication side effects such as anticholinergics or dehydration, rather than liver toxicity from acetaminophen overdose.

B. Constipation: Constipation does not commonly result from acetaminophen toxicity. Instead, gastrointestinal upset such as nausea, anorexia, and vomiting are more likely due to impaired liver function and toxin buildup.

C. Vomiting: Acetaminophen overdose primarily affects the liver, leading to hepatotoxicity. By 72 hours, clinical signs such as vomiting, right upper quadrant pain, jaundice, and elevated liver enzymes can appear as manifestations of poisoning.

D. Tinnitus: Tinnitus is more commonly associated with salicylate (aspirin) toxicity. Acetaminophen overdose does not typically cause auditory disturbances but instead presents with gastrointestinal and hepatic symptoms.

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Correct Answer is A

Explanation

A. Serosanguineous: This type of drainage is watery and pink to light red, reflecting a mixture of plasma (serous fluid) and small amounts of blood. It is commonly seen in the early stages of wound healing and is the most accurate description of watery red drainage.

B. Sanguineous: Sanguineous drainage is primarily composed of blood, making it thicker and bright red. It usually indicates active bleeding and would not appear watery in consistency.

C. Serous: Serous drainage is clear or slightly yellow and watery, resembling plasma. It does not contain red blood cells, so it would not appear red or pink.

D. Purulent: Purulent drainage is thick, opaque, and often green, yellow, or brown due to infection and the presence of white blood cells, bacteria, and cellular debris not watery red drainage.

A. Ask the patient to share the teaching with a neighbor or friend soon after discharge. B. Give the patient detailed written information about each drug. C. Cluster medication administration times as much as possible. D. Make sure the patient understands the actions and side effects of each drug.

Correct Answer is C

Explanation

A. Ask the patient to share the teaching with a neighbor or friend soon after discharge: While social support can reinforce learning, relying on a neighbor or friend may not guarantee medication adherence. This does not directly address the patient’s forgetfulness or simplify the regimen.

B. Give the patient detailed written information about each drug: Providing written information is helpful, but detailed instructions may overwhelm a forgetful older adult. Without strategies to simplify administration, written material alone is unlikely to ensure adherence.

C. Cluster medication administration times as much as possible: Simplifying the regimen by reducing the number of administration times makes it easier for a forgetful patient to follow. Fewer scheduled doses support adherence and reduce the risk of missed medications.

D. Make sure the patient understands the actions and side effects of each drug: Understanding medications is important, but a forgetful patient may struggle with recall. While teaching remains necessary, simplifying the schedule is more effective in promoting adherence.

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A nurse is monitoring a client who took an overdose of acetaminophen 72 hr ago. The nurse should identify which of the following findings as a manifestation of acetaminophen poisoning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

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