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
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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Related Questions
Correct Answer is B
Explanation
A. Stress incontinence: Stress incontinence occurs when small amounts of urine leak due to increased intra-abdominal pressure, such as coughing, sneezing, or exercising. It is related to weakened pelvic floor muscles, not nerve damage.
B. Reflex incontinence: Reflex incontinence happens when nerve damage from conditions like spinal cord injury prevents voluntary control of urination. The bladder empties reflexively once it reaches a certain volume, leading to involuntary leakage.
C. Overflow incontinence: Overflow incontinence results from bladder overdistention due to obstruction or underactive bladder muscles. It is characterized by frequent dribbling of urine rather than reflexive emptying caused by nerve injury.
D. Urge incontinence: Urge incontinence involves a sudden, intense urge to urinate followed by involuntary leakage. It is commonly linked to overactive bladder but is not typically associated with spinal cord nerve damage.
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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