Interpret these clinical findings and determine the nurse's next action.

Clinical Findings:

Complaints of dizziness and unsteady gait.

BP: 98/60 mmHg.

Carbidopa-Levodopa last taken 30 minutes ago.

Reassess vital signs in 1 hour.

Assist the patient into a sitting position and notify the healthcare provider.

Administer the next dose of Carbidopa-Levodopa early.

Educate the patient about increasing his exercise.

Answer and Explanation

The Correct Answer is B

Choice A reason: Reassessing vital signs in 1 hour is not an immediate action and does not address the patient’s current symptoms of dizziness and unsteady gait, which indicate a potential problem that requires immediate attention. Waiting an hour to reassess may delay necessary interventions that could prevent harm.
Choice B reason: Assisting the patient into a sitting position and notifying the healthcare provider is the most appropriate action. The symptoms of dizziness and unsteady gait, along with a BP of 98/60 mmHg, suggest that the patient may be experiencing orthostatic hypotension or a side effect of Carbidopa-Levodopa. Elevating the patient's position can help prevent falls, and notifying the healthcare provider ensures that the situation is assessed and managed promptly. This action addresses the immediate safety of the patient and facilitates appropriate medical intervention.
Choice C reason: Administering the next dose of Carbidopa-Levodopa early is not recommended without specific orders from the healthcare provider. It could potentially lead to overmedication and worsen the patient’s symptoms or cause adverse effects. Medication administration should always follow the prescribed schedule unless otherwise directed by the healthcare provider.
Choice D reason: Educating the patient about increasing his exercise is important for overall health and mobility but is not an immediate intervention for the acute symptoms of dizziness and unsteady gait. The patient’s current condition requires prompt assessment and intervention rather than education on exercise, which can be addressed later once the immediate issue is managed.

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Correct Answer is C

Explanation

Choice A reason: An elevated blood pressure of 148/84 mm Hg is significant and could be related to prednisone use, as corticosteroids can increase blood pressure. However, this finding alone is not as urgent as the abrupt cessation of prednisone, which can lead to adrenal insufficiency and other serious complications.
Choice B reason: Not taking prescribed vitamin D is important, especially in long-term corticosteroid therapy, as vitamin D helps mitigate the risk of bone density loss. However, this issue is not as immediately critical as abruptly stopping prednisone.
Choice C reason: Stopping prednisone abruptly after taking it for 3 weeks is critical information that must be reported to the healthcare provider immediately. Prednisone is a corticosteroid that suppresses the adrenal glands' ability to produce natural steroids. Abrupt discontinuation can lead to adrenal insufficiency, which can be life-threatening. Symptoms of adrenal insufficiency include severe fatigue, weakness, body aches, low blood pressure, and potential shock. Gradual tapering is required to allow the adrenal glands to recover and resume natural steroid production.
Choice D reason: Bilateral 2+ pitting ankle edema is a notable finding and may indicate fluid retention, which can be a side effect of prednisone. While it is important and requires monitoring, it does not carry the same immediate risk as the abrupt cessation of the medication.

A. Cardiac dysrhythmias, Hypotension, and pain B. Fluid and electrolyte imbalance, Hypotension, and Wound dehiscence C. Inadequate diet, Wound dehiscence, Hypotension D. Infection, Fluid and electrolyte imbalance, and pain

Correct Answer is D

Explanation

Choice A reason: Cardiac dysrhythmias are not the primary concern in a patient with acute cholecystitis. Although severe pain can lead to stress on the cardiovascular system, it is not the main priority in this scenario. Hypotension can be a concern due to dehydration from vomiting, but pain management is addressed more comprehensively under fluid and electrolyte balance and infection control.
Choice B reason: Wound dehiscence is not relevant in this case as the patient has not undergone surgery yet. Fluid and electrolyte imbalance and hypotension are important considerations due to the patient’s nausea and vomiting, but wound dehiscence does not apply to her current state of care.
Choice C reason: The inadequate diet is a consideration due to the patient's inability to eat or drink, and hypotension is a risk due to dehydration. However, wound dehiscence is still not relevant since the patient has not had a surgical procedure yet. Preventing an inadequate diet is part of the broader management but not the immediate priority.
Choice D reason: Infection, fluid and electrolyte imbalance, and pain are the most relevant concerns for a patient with acute cholecystitis. The nasogastric tube and IV fluids are vital for managing her dehydration and electrolyte imbalances. The patient's high pain level (9/10) indicates severe discomfort that must be managed effectively. Additionally, with the insertion of a nasogastric tube and the risk of cholecystitis-related complications, preventing infection is a key priority.

View Question and Answer

Test	Result	Normal Range
ALT (Alanine Aminotransferase)	1.200 U/L	7-56 U/L
AST (Aspartate Aminotransferase)	1.000 U/L	10-40 U/L
Total Bilirubin	5.5 mg/dL	0.1-1.2 mg/dL
Hepatitis A IgM	Positive	Negative

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Interpret these clinical findings and determine the nurse's next action. Clinical Findings: Complaints of dizziness and unsteady gait. BP: 98/60 mmHg. Carbidopa-Levodopa last taken 30 minutes ago.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which information obtained by the nurse in the clinic about a patient who has been taking prednisone 40 mg daily for 3 weeks is most important to report to the health care provider?

Correct Answer is C

Explanation

Based on the patient's current condition, the nurse recognizes that the patient's priority needs will be to prevent:

Correct Answer is D

Explanation

An adult male is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms?

A patient who is disoriented and reports a headache and muscle cramps is hospitalized with syndrome of inappropriate antidiuretic hormone (SIADH). Which initial laboratory result would the nurse expect?

A 23-year-old college student is diagnosed with hepatitis A after returning from an international trip. During health education, the nurse explains how hepatitis A is transmitted. Which statement by the patient indicates a correct understanding of how the virus is spread?

Which finding indicates to the nurse that the current therapies are effective for a patient who has Addison's disease?

Which patient statement indicates to the nurse that further instruction is needed about chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

Interpret these clinical findings and determine the nurse's next action.

Clinical Findings:

Complaints of dizziness and unsteady gait.

BP: 98/60 mmHg.

Carbidopa-Levodopa last taken 30 minutes ago.