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 ["D","E","F"]
Explanation
Choice A reason: A tongue blade is not typically necessary for a patient with status epilepticus. It is more commonly used for oral care or to check the throat, but it is not essential in this context.
Choice B reason: A urinary catheter is not necessary unless the patient has specific urinary retention issues or requires accurate measurement of urine output. It is not standard equipment for managing status epilepticus.
Choice C reason: A nasogastric tube is not typically required for status epilepticus unless there are specific gastrointestinal issues that need to be addressed. It is not standard equipment for managing status epilepticus.
Choice D reason: A suction set up is essential for a patient with status epilepticus to manage potential airway secretions and prevent aspiration. It ensures that the airway remains clear and reduces the risk of complications.
Choice E reason: An oxygen mask is crucial for a patient with status epilepticus to ensure adequate oxygenation. It helps maintain oxygen levels and supports respiratory function, especially if the patient experiences respiratory distress.
Choice F reason: Side-rail pads are important for patient safety, particularly for a patient with status epilepticus who may be at risk of falls or injury during seizures. They provide a protective barrier and help prevent accidental injury.
Correct Answer is A
Explanation
Choice A reason: Hepatic encephalopathy is a severe complication of cirrhosis caused by elevated serum ammonia levels. When the liver is unable to effectively remove ammonia from the blood due to cirrhosis, ammonia accumulates and crosses the blood-brain barrier, leading to neurological symptoms such as confusion, altered mental status, and even coma. This condition is directly related to the liver's impaired ability to detoxify the blood, making it the most consistent complication associated with elevated serum ammonia levels.
Choice B reason: Jaundice is a common symptom of cirrhosis, but it is not directly caused by elevated serum ammonia levels. Jaundice occurs due to the liver's inability to process bilirubin, a byproduct of red blood cell breakdown, leading to its accumulation in the blood and tissues. While jaundice is a sign of liver dysfunction, it is not specifically linked to ammonia levels.
Choice C reason: Ascites is the accumulation of fluid in the abdominal cavity and is a common complication of cirrhosis. It occurs due to portal hypertension and hypoalbuminemia, which result from liver dysfunction. Although ascites is a significant complication, it is not directly caused by elevated serum ammonia levels.
Choice D reason: Peripheral neuropathies are nerve damage that can occur in various conditions, but they are not typically associated with elevated serum ammonia levels in cirrhosis. Peripheral neuropathies can result from nutritional deficiencies, metabolic disorders, or other underlying conditions, but they are not a direct consequence of ammonia accumulation.
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