An older adult client with heart failure comes to the emergency room because of nausea, vomiting, and anorexia. Based on the client's signs and symptoms, which data from the medical history has the most significance when planning this client's care?

Coronary artery bypass procedure was performed in 1995.

Colonoscopy performed for routine screening six months ago.

Digoxin and furosemide daily since 1996.

Suffered with depression following death of spouse in 1999.

Answer and Explanation

The Correct Answer is C

A. The history of coronary artery bypass surgery is important but does not directly relate to the current symptoms.
B. A recent colonoscopy is not relevant to the client's current symptoms.
C. Long-term use of digoxin and furosemide is highly significant as these medications can lead to digoxin toxicity, especially in the context of dehydration or renal insufficiency. Symptoms like nausea, vomiting, and anorexia are classic signs of digoxin toxicity.
D. A history of depression is important but not immediately relevant to the current symptoms of nausea, vomiting, and anorexia.

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Correct Answer is D

Explanation

A. Lubricating lotion may be helpful for dry skin but is not necessary for these lesions.
B. A biopsy is not typically required for benign lesions such as senile lentigines, unless there is suspicion of malignancy.
C. Recent international travel is unrelated to the development of senile lentigines.
D. Senile lentigines, also known as "liver spots" or "age spots," are common in older adults. They are benign lesions that result from sun exposure and aging. Recording their presence is appropriate for documentation, as they are generally not harmful.

A. Determine if the client is taking an anticholinergic drug such as benztropine mesylate. B. This is an expected side effect of chlorpromazine which requires no further action. C. Call the healthcare provider and refuse to administer any more chlorpromazine. D. Decrease the dose of chlorpromazine and notify the healthcare provider.

Correct Answer is A

Explanation

A. Spasms of the neck and back can be symptoms of acute dystonia, a side effect of antipsychotic medications like chlorpromazine. Anticholinergic drugs such as benztropine mesylate can help manage these symptoms.
B. Spasms are not an expected side effect of chlorpromazine and require intervention rather than acceptance.
C. Refusing to administer chlorpromazine without consulting the healthcare provider may be premature; the priority is to address the symptoms.
D. Decreasing the dose and notifying the healthcare provider may be necessary, but first, it’s essential to determine if anticholinergic medication is required to address the acute symptoms.

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An older adult client with heart failure comes to the emergency room because of nausea, vomiting, and anorexia. Based on the client's signs and symptoms, which data from the medical history has the most significance when planning this client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

Correct Answer is A

Explanation

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

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While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

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