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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: 3% Normal Saline (3% NaCl) is not appropriate for treating acute Diabetes insipidus because it is hypertonic and can exacerbate dehydration, which is a primary concern in DI.
Choice B reason: Dextrose 5% in water (D5W) is appropriate for treating acute Diabetes insipidus as it provides free water without electrolytes, helping to correct the water deficit without causing electrolyte imbalances.
Choice C reason: Lactated Ringer's (LR) is not suitable for treating acute Diabetes insipidus because it contains electrolytes that can worsen the electrolyte imbalance in DI patients.
Choice D reason: Normal Saline (0.9% NaCl) can be used for treating acute Diabetes insipidus but it is not the most appropriate choice as it does not provide free water, which is needed to address the water deficit in DI patients.
Correct Answer is C
Explanation
Choice A reason: Increased serum chloride is not a typical finding associated with syndrome of inappropriate antidiuretic hormone (SIADH). In SIADH, the body's regulation of water is impaired, leading to water retention and dilutional hyponatremia. Serum chloride levels might not be significantly affected and are not the primary laboratory indicator for this condition.
Choice B reason: Elevated hematocrit is not directly related to SIADH. Hematocrit levels reflect the proportion of red blood cells in the blood. In SIADH, the main issue is water retention leading to dilutional hyponatremia, rather than changes in red blood cell concentration. Therefore, hematocrit levels are not a key laboratory finding in this disorder.
Choice C reason: Decreased serum sodium, or hyponatremia, is a hallmark finding in SIADH. The excessive release of antidiuretic hormone (ADH) leads to water retention, diluting the sodium in the blood and resulting in low serum sodium levels. This hyponatremia can cause symptoms such as disorientation, headache, and muscle cramps, as seen in the patient. Monitoring and correcting serum sodium levels is crucial in the management of SIADH.
Choice D reason: Low urine specific gravity is not expected in SIADH. In fact, patients with SIADH typically have a high urine specific gravity due to the excessive release of ADH, which causes the kidneys to reabsorb water and concentrate the urine. This concentrated urine reflects the body's attempt to reduce water excretion in response to elevated ADH levels. Therefore, low urine specific gravity would not be an initial laboratory finding in this condition.
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