An elderly client was given a dose of Ambien PO at bedtime for sleep and she was wide awake all night instead of going to sleep.
This adverse reaction to a drug could be classified as a/an:
Drug allergy.
Drug tolerance.
Toxic effect.
Idiosyncratic reaction.
The Correct Answer is D
Choice A rationale
A drug allergy is an adverse immune-mediated reaction to a drug, involving antibodies or sensitized lymphocytes. Symptoms can range from rash and itching to anaphylaxis, occurring upon re-exposure. This client's reaction, wakefulness instead of sedation, does not align with typical allergic manifestations involving the immune system.
Choice B rationale
Drug tolerance is a diminished physiological response to a drug after repeated administration, requiring higher doses to achieve the same effect. This develops due to adaptive changes in drug receptors or metabolism. The client's experience of wakefulness, an opposite effect, is not indicative of tolerance to the drug's intended hypnotic action.
Choice C rationale
A toxic effect occurs when drug levels in the body exceed the therapeutic range, leading to harmful effects on organs or systems. This is often dose-dependent and can manifest as organ damage or severe side effects. While adverse, the described reaction of wakefulness is not typically classified as a toxic effect of Ambien.
Choice D rationale
An idiosyncratic reaction is an uncharacteristic or unpredictable response to a drug that is not an allergic reaction and does not involve known pharmacological properties. These reactions are often genetically determined and represent an individual's unique sensitivity. The paradoxical wakefulness from a sedative like Ambien is a classic example of an idiosyncratic drug response.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Inspection is the systematic observation of the patient using the senses of sight, smell, and hearing. It is always the first technique used in a physical assessment because it provides a foundational understanding of the patient's general appearance, symmetry, posture, skin condition, and any visible abnormalities before physical contact is made.
Choice B rationale
Auscultation involves listening to sounds produced by the body, such as heart sounds, lung sounds, and bowel sounds, using a stethoscope. While crucial for assessing various body systems, it typically follows inspection and palpation to avoid altering natural body sounds.
Choice C rationale
Percussion involves tapping on body surfaces to elicit sounds that indicate the density of underlying tissues and organs. This technique helps in assessing organ size, shape, and consistency, but it is performed after inspection and palpation, as it involves direct contact and manipulation.
Choice D rationale
Palpation involves using the sense of touch to assess characteristics such as texture, temperature, moisture, organ size and location, and tenderness. While a vital component of the physical assessment, it follows inspection to avoid introducing discomfort or altering initial observations.
Correct Answer is ["68"]
Explanation
Step 1 is: Add the ordered units of Humulin NPH and Humulin R insulin.
Step 2 is: 52 units + 16 units = 68 units. Answer: The nurse will administer 68 units. (Shade SYRINGE #3 to the 68-unit mark).
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