In conducting a health history for a client with erythema, the nurse would include which question?
Do you ever use oxygen?
How many pillows do you sleep on?
Do you feel rested after sleeping?
How far can you walk before feeling short of breath?
The Correct Answer is A
Choice A reason: The nurse would include the question of whether the client ever uses oxygen, as this can be related to erythema. Erythema is a condition where the skin becomes red and inflamed due to increased blood flow or irritation. ¹ One possible cause of erythema is oxygen toxicity, which is a condition where the lungs and tissues are damaged by exposure to high levels of oxygen. ² The nurse would ask the client if they ever use oxygen, especially at high concentrations or for long periods of time, as this can increase the risk of oxygen toxicity and erythema.
Choice B reason: The nurse would not include the question of how many pillows the client sleeps on, as this is not related to erythema. The number of pillows the client sleeps on may indicate the presence of other conditions, such as sleep apnea, acid reflux, or heart failure, but not erythema. ³ The nurse would ask the client about their sleeping habits and preferences, but not specifically about the number of pillows they use.
Choice C reason: The nurse would not include the question of whether the client feels rested after sleeping, as this is not related to erythema. The feeling of restfulness after sleeping may indicate the quality and quantity of sleep the client gets, which can affect their overall health and well-being, but not erythema. The nurse would ask the client about their sleep patterns and problems, but not specifically about their feeling of restfulness.
Choice D reason: The nurse would not include the question of how far the client can walk before feeling short of breath, as this is not related to erythema. The distance the client can walk before feeling short of breath may indicate the level of physical activity and fitness the client has, which can affect their cardiovascular and respiratory health, but not erythema. The nurse would ask the client about their exercise habits and limitations, but not specifically about their walking distance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The client had an allergic reaction to losartan, a drug that belongs to the class of angiotensin II receptor blockers (ARBs). ¹ Anaphylaxis is a severe and potentially life-threatening allergic reaction that can cause swelling of the lips, tongue, throat, and face, as well as difficulty breathing, low blood pressure, and shock. ² The client needs immediate medical attention and treatment with oxygen, fluids, and epinephrine. ³
Choice B reason: The client did not have an expected side effect of the medication. Losartan is used to treat high blood pressure and heart failure by blocking the action of angiotensin II, a hormone that causes blood vessels to constrict and retain salt and water. ¹ Some common side effects of losartan include dizziness, headache, fatigue, cough, and nausea. ⁴ Anaphylaxis is not a common or expected side effect of losartan, but a rare and serious adverse reaction.
Choice C reason: The client should not have a prescription change to enalapril. Enalapril is another drug that lowers blood pressure and heart failure, but it belongs to the class of angiotensin-converting enzyme (ACE) inhibitors. ⁵ ACE inhibitors and ARBs have similar mechanisms of action and effects, but they differ in how they block the angiotensin system. However, both classes of drugs can cause allergic reactions and anaphylaxis in some people, especially those who have a history of allergy to either drug. The client should avoid both ACE inhibitors and ARBs and use another type of blood pressure medication.
Choice D reason: The client should not avoid taking the medication with food. Food does not affect the absorption or effectiveness of losartan. ⁴ The client can take the medication with or without food, as directed by the provider. However, the client should avoid grapefruit and grapefruit juice, as they can interact with losartan and increase the risk of side effects.
Correct Answer is C
Explanation
Choice A reason: You feel good because your medication is working properly is not the most appropriate statement by the nurse. This statement may imply that the client does not need to worry about their blood pressure or follow up with their doctor. The nurse should educate the client about the importance of regular monitoring and adherence to the prescribed treatment.
Choice B reason: Your blood pressure reflects how strong your heart muscle contracts is not the most appropriate statement by the nurse. This statement may confuse the client or give them a false sense of security. The nurse should explain that blood pressure is determined by the force and amount of blood pumped by the heart and the resistance of the blood vessels. The nurse should also inform the client about the normal and abnormal ranges of blood pressure and the risk factors for hypertension.
Choice C reason: Even if you are feeling good, damage can occur to your heart and kidneys is the most appropriate statement by the nurse. This statement conveys the seriousness of hypertension and its potential complications. The nurse should educate the client about the effects of high blood pressure on the vital organs and the need for preventive measures and lifestyle modifications.
Choice D reason: Have you told your doctor that you are feeling good is not the most appropriate statement by the nurse. This statement may suggest that the nurse is not interested in the client's condition or does not have the knowledge or authority to address their concerns. The nurse should communicate effectively with the client and the health care team and provide appropriate guidance and support.
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