A nurse is providing client education to a client who is taking over the counter (OTC) acetaminophen.
The nurse should incorporate which of the following teaching?
Measure your blood pressure prior to taking the medication.
Should you notice bleeding gums and bruising contact your health provider.
Observe your stool for any bright red color and/or black tarry color.
Do not take more than 4g in a 24-hour period as it may lead to hepatotoxicity.
The Correct Answer is D
Choice A rationale
Monitoring blood pressure is generally not a required intervention specifically for acetaminophen administration because it does not have the same immediate vasoconstrictive or renal effects that typically elevate systemic blood pressure in the way that NSAIDs do. While general health monitoring is important, acetaminophen lacks the prostaglandin inhibition in the kidneys that would lead to fluid retention or significant hypertension in most patients.
Choice B rationale
Bleeding gums and easy bruising are clinical signs typically associated with anticoagulant therapy or disorders affecting platelet aggregation. Acetaminophen is not a primary anticoagulant and does not significantly interfere with the clotting cascade or platelet function at therapeutic doses. Therefore, these specific symptoms are not the primary adverse effects that a nurse would instruct a patient to monitor when taking this specific medication.
Choice C rationale
Observing for bright red or black tarry stools is a common instruction for patients taking nonsteroidal anti-inflammatory drugs because those medications can cause gastric ulceration and gastrointestinal bleeding. Acetaminophen is a non-opioid analgesic that primarily works in the central nervous system and has minimal effects on gastric mucosa, making the risk for gastrointestinal hemorrhage significantly lower than that of aspirin or ibuprofen.
Choice D rationale
The maximum recommended dose of acetaminophen for a healthy adult is 4000 mg or 4 g in a 24-hour period to prevent severe liver damage. Metabolism occurs via the liver, and excessive intake exhausts glutathione stores, leading to the accumulation of toxic metabolites like NAPQI. This can cause irreversible centrilobular necrosis. Patients must be taught to read all OTC labels to avoid accidental overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Opioids are typically reserved for severe, chronic pain that does not respond to other therapies and are not considered first-line treatment for rheumatoid arthritis. They provide analgesia but do not address the underlying inflammatory processes or provide the anti-inflammatory benefits necessary to manage joint swelling and prevent damage. Furthermore, the risk for dependence and respiratory depression makes them less ideal for initial management.
Choice B rationale
Acetaminophen is an effective analgesic for mild to moderate pain, but it lacks significant anti-inflammatory properties. Because rheumatoid arthritis is a chronic systemic inflammatory disease characterized by synovitis and joint destruction, acetaminophen alone is insufficient for primary treatment. It might be used as an adjunct for pain control, but it cannot replace medications that actively target the inflammatory response occurring within the joints.
Choice C rationale
Nonsteroidal anti-inflammatory drugs are the first-line choice for managing the immediate symptoms of rheumatoid arthritis, such as pain and inflammation. They work by inhibiting cyclooxygenase enzymes, which reduces the production of prostaglandins that mediate the inflammatory response. While they do not slow the progression of the disease like DMARDs, they are essential for providing rapid symptomatic relief during the initial diagnostic and treatment phases.
Choice D rationale
Hormone replacement therapy is used to manage symptoms related to hormonal deficiencies, such as those occurring during menopause, and has no established role as a primary treatment for rheumatoid arthritis. While hormonal shifts can sometimes influence autoimmune conditions, HRT does not provide the analgesic or anti-inflammatory effects required to manage the joint inflammation and pain that characterize a new diagnosis of rheumatoid arthritis.
Correct Answer is D
Explanation
Choice A rationale
While certain medications like anticholinergics or corticosteroids can affect vision or lead to cataracts and glaucoma, they are not the primary cause of age-related loss of near vision. The client's progressive trouble with close vision at age 45 is a classic physiological change. Attributing the change solely to medications ignores the natural aging process of the eye. A thorough history would be needed, but this statement does not show an understanding of presbyopia.
Choice B rationale
Eye trauma can cause various visual disturbances, including retinal detachment or traumatic cataracts, which might affect vision at any distance. However, trauma usually results in sudden or localized changes rather than a bilateral, progressive difficulty with near work. If the client had no history of injury, this explanation is incorrect. Understanding the problem involves recognizing that the lens loses elasticity over time, which is a developmental change rather than an accidental one.
Choice C rationale
Chronic hypertension can lead to hypertensive retinopathy, which may cause blurred vision or vision loss due to vascular damage in the retina. While maintaining blood pressure is vital for ocular health, it is not the typical reason a 45-year-old begins to struggle specifically with reading or close-up tasks. Presbyopia is a refractive error related to lens flexibility, whereas hypertension affects the vascular integrity of the eye. Therefore, this statement indicates a misunderstanding of the condition.
Choice D rationale
Presbyopia is the age-related loss of the eye's ability to focus actively on nearby objects. It typically becomes noticeable in the early to mid-40s as the crystalline lens loses elasticity and the ciliary muscles weaken. When the client identifies these symptoms as early signs of presbyopia, it demonstrates they understand the explanation of the natural aging process. This condition is easily corrected with reading glasses or bifocals and is considered a normal part of aging.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.