Exhibits

A nurse is reviewing the client’s condition. Based on the exhibits provided, what is the most likely diagnosis for this client?

Rationale for Choice A:

Observing for edema around the ankles is a relevant assessment, but it's not the most crucial one in this context. Edema can be a sign of fluid retention, which is a potential side effect of hydromorphone. However, it's not the most immediate or dangerous concern associated with prolonged hydromorphone use.

Rationale for Choice B:

Counting the apical and radial pulses simultaneously is a technique used to assess for pulse deficits, which can indicate heart rhythm irregularities. While hydromorphone can potentially cause cardiac effects, it's not the most common or primary concern with its use. Other assessments take priority.

Rationale for Choice C:

Measuring the patient's capillary glucose level is important for patients with diabetes or those at risk for hyperglycemia. However, there's no direct link between hydromorphone use and blood glucose levels. This assessment isn't the most relevant in this specific scenario.

Rationale for Choice D:

Auscultating the patient's bowel sounds is the most important assessment for a patient who has been receiving hydromorphone for four days. Here's why:

Hydromorphone is a potent opioid analgesic that can significantly slow down gastrointestinal motility. This can lead to constipation, which, if severe, can progress to ileus (a complete lack of bowel movement).

Ileus is a serious complication that can cause abdominal pain, bloating, nausea, vomiting, and even bowel obstruction or perforation if left untreated.

Auscultating bowel sounds helps assess the patient's bowel activity and detect early signs of constipation or ileus. Normal bowel sounds are typically heard every 5-15 seconds. Decreased or absent bowel sounds can indicate decreased bowel activity.

Early identification of constipation or ileus allows for prompt intervention, such as increasing fluid and fiber intake, administering laxatives or stool softeners, and potentially discontinuing or adjusting the hydromorphone dosage. This can prevent the development of more serious complications.

Therefore, auscultating the patient's bowel sounds is the most important assessment for the nurse to complete in this case, as it directly addresses the most significant potential complication associated with prolonged hydromorphone use.

The correct answer is choice D. Reported history of alcoholism.

Choice A rationale:

Employment as a construction worker is not directly relevant to the administration of terbinafine HCL. While it may affect the client’s overall health and risk of injury, it does not impact the medication’s safety or efficacy.

Choice B rationale:

A white blood cell count of 8,500/mm³ (8.5 x 10³/L) is within the normal range and does not indicate any immediate concern that would affect the administration of terbinafine HCL.

Choice C rationale:

Thick and yellow toenails are typical symptoms of a fungal toenail infection and are the reason for prescribing terbinafine HCL. This finding confirms the diagnosis but does not present a contraindication to the medication.

Choice D rationale:

A reported history of alcoholism is crucial to address because terbinafine HCL can cause liver toxicity. Clients with a history of alcoholism are at higher risk for liver damage, and this must be carefully evaluated before starting the medication.