Exhibits
The nurse is evaluating the client's progress and nursing implementations.
Click to high light the findings that would indicate the client has recovered from the adverse drug reaction.
1230:
Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored. Drowsy.
Shaking is lessened
Client is no longer flushed
No longer itching
Anxiety has decreased
Skin warm and dry
Heart rate 62 beats/minute, blood pressure 130/72 mm Hg
No chest pain noted
Respirations are even and unlabored
Drowsy
The Correct Answer is ["A","B","C","D","E","F","G","H","I"]
- Shaking is lessened: Shaking or tremors can be a manifestation of the body's response to stress or discomfort. A decrease in shaking suggests that the client's physiological response is returning to normal, indicating improvement.
- Client is no longer flushed: Flushing, or the reddening of the skin, can occur as a result of vasodilation during an allergic reaction or due to increased blood flow associated with elevated body temperature. The absence of flushing suggests that the body's inflammatory response has subsided, indicating resolution of the adverse reaction.
- No longer itching: Itching, or pruritus, is a common symptom of allergic reactions mediated by histamine release. The cessation of itching suggests that the inflammatory mediators responsible for the itching response have been cleared from the body, indicating resolution of the allergic reaction.
- Anxiety has decreased: Anxiety can be a psychological response to physical discomfort or distress. A decrease in anxiety levels suggests that the client is experiencing less discomfort and is psychologically improving, which can be indicative of recovery from the adverse drug reaction.
- Skin warm and dry: Warm and dry skin is a sign of normal thermoregulation and hydration status. The presence of warm and dry skin suggests that the client's body temperature and hydration levels are within normal limits, indicating physiological stability and recovery from the adverse drug reaction.
- Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: Vital signs within normal limits, including a heart rate and blood pressure within the client's baseline range, indicate stability of cardiovascular function and resolution of any hemodynamic instability associated with the adverse drug reaction.
- No chest pain noted: Chest pain can be indicative of cardiovascular compromise or ischemia. The absence of chest pain suggests that the client's cardiovascular function has normalized, further supporting recovery from the adverse drug reaction.
- Respirations are even and unlabored: Even and unlabored respirations indicate normal respiratory function and adequate gas exchange. The absence of respiratory distress or effort suggests resolution of any respiratory complications associated with the adverse drug reaction.
- Drowsy: Drowsiness can be a side effect of medications such as antihistamines or a natural response to the body's recovery process. While drowsiness may persist for a period after the adverse drug reaction resolves, its presence alongside other signs of improvement suggests that the client's body is returning to a state of equilibrium.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client is stable with no drainage from the Jackson-Pratt drain, indicating that there is no immediate issue that needs to be addressed. The bulb is compressed, suggesting proper function. Therefore, this client can be safely assessed last.
B. An adult client with a rectal tube draining clear, pale red liquid drainage. The presence of pale red drainage can indicate a potential issue that needs monitoring, such as bleeding or other complications, thus requiring a more timely assessment.
C. An older client with a distended abdomen and no drainage from the nasogastric tube. A distended abdomen and lack of drainage could indicate a blockage or other serious issue that needs immediate attention.
D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. Dark red drainage can indicate active bleeding, which is a critical issue that needs to be addressed promptly to prevent complications.
Correct Answer is C
Explanation
A. Core strengthening. While important for overall health, core strengthening is not as directly effective for osteoporosis prevention as weight-bearing exercise.
B. Aerobic exercise. Aerobic exercise is beneficial for cardiovascular health but does not have the same bone-strengthening effect as weight-bearing exercise.
C. Weight-bearing exercise. Weight-bearing exercises, such as walking, jogging, and strength training, are essential for maintaining bone density and preventing osteoporosis.
D. Muscle stretching and toning. Stretching and toning are important for flexibility and muscle health but do not significantly impact bone density compared to weight-bearing exercises.
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