Patient Data

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Tardive dyskinesia is most likely because the client exhibits rhythmic tongue protrusion and involuntary facial and shoulder movements, classic signs after chronic chlorpromazine use. Long-term dopamine blockade causes these irreversible motor symptoms.
Anaphylaxis typically presents with airway compromise, rash, hypotension, and tachycardia. The client's stable respiratory status and isolated involuntary movements are not consistent with an allergic reaction.
Postural hypotension would involve symptoms like dizziness or fainting on position changes, which are not described. The client's blood pressure is stable, and there are no signs of orthostatic intolerance.
Opioid withdrawal usually presents with symptoms such as agitation, sweating, diarrhea, and abdominal cramping. The client’s involuntary muscle movements are neurologic, not signs of opioid withdrawal.
Give diphenhydramine IV is indicated for acute dystonic reactions, not tardive dyskinesia. Tardive dyskinesia requires different management focused on antipsychotic adjustment, not antihistamine therapy.
Assess the client's medication history is important because chronic exposure to first-generation antipsychotics like chlorpromazine strongly increases the risk for tardive dyskinesia. Understanding medication use helps confirm diagnosis and guide treatment.
Give a bolus of IV fluids is unrelated to involuntary motor symptoms. There is no evidence of dehydration or shock, and IV fluids will not address tardive dyskinesia.
Hold the next dose of chlorpromazine is essential because continued dopamine receptor blockade can worsen the severity and permanence of tardive dyskinesia. Discontinuing or adjusting medication is a priority intervention.
Initiate fall precautions could be reasonable for overall safety but is secondary to addressing the medication cause. The priority is to stop progression of symptoms by modifying the antipsychotic regimen.
Mental status should be closely monitored because clients with neurologic side effects may experience confusion, worsening agitation, or other mental changes, especially when medications are adjusted.
Pulse deficit monitoring is not clinically useful in tardive dyskinesia. It is more relevant in assessing cardiac arrhythmias and is not connected to the client's neurologic symptoms.
Respiratory rate monitoring is important generally but does not directly assess for the progression or resolution of tardive dyskinesia, which affects motor function rather than breathing.
Standing blood pressure is useful when evaluating for postural hypotension, but there is no evidence suggesting orthostatic instability in this client’s presentation.
Extrapyramidal symptoms must be continuously monitored because their worsening or improvement will guide the need for further neurologic evaluation and possible medication adjustments.

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Correct Answer is C

Explanation

A. Consume foods that are high in iodine: While iodine is necessary for thyroid function, levothyroxine therapy is aimed at directly replacing thyroid hormone. Excessive iodine intake can potentially disrupt thyroid hormone balance, so encouraging high iodine consumption is not the primary focus when educating about levothyroxine use.

B. Administer levothyroxine at bed time: Levothyroxine is best absorbed when taken in the morning on an empty stomach, ideally 30 to 60 minutes before breakfast. Taking it at bedtime could reduce its absorption if the stomach is not empty or if it interacts with food or other nighttime medications.

C. Take medication on an empty stomach: Levothyroxine absorption is significantly improved when the medication is taken on an empty stomach, separated from food and other medications by at least 30 to 60 minutes. This practice ensures optimal therapeutic effects and maintains stable thyroid hormone levels.

D. Avoid the use of iron supplements: While iron supplements can interfere with the absorption of levothyroxine, the instruction is not necessarily to avoid them altogether, but rather to separate their administration by several hours (usually 4 hours) from the levothyroxine dose to ensure proper absorption of both.

A. Document the assessment findings in the electronic health record. B. Explain that the medication takes several weeks to reverse symptoms. C. Advise the client to schedule an appointment for liver function tests. D. Withhold the medication until the healthcare provider is notified.

Correct Answer is A

Explanation

A. Document the assessment findings in the electronic health record: Riluzole is not curative for ALS; it only modestly slows disease progression. Continuing muscle weakness and atrophy are expected findings in ALS, even after starting treatment. Accurate documentation is appropriate because no immediate change in therapy is indicated based solely on these observations.

B. Explain that the medication takes several weeks to reverse symptoms: Riluzole does not reverse ALS symptoms. It may slightly prolong survival by slowing the progression of muscle weakness, but it does not regenerate lost function or reverse disease-related damage.

C. Advise the client to schedule an appointment for liver function tests: Riluzole can affect liver function and periodic monitoring is important, but muscle weakness alone does not directly signal liver problems. Unless there are signs of hepatotoxicity, there is no immediate need for unscheduled testing.

D. Withhold the medication until the healthcare provider is notified: There is no indication to withhold riluzole based on ongoing muscle weakness, as this is consistent with the natural course of ALS. Interrupting therapy without a clear medical reason could harm the client.

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Patient Data Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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Naxlex Comprehensive Predictor Exams

A client receives a new prescription for levothyroxine. Which statement made by the client indicates to the nurse education was effective?

Correct Answer is C

Explanation

A client with amyotrophic lateral sclerosis (ALS) has been taking riluzole for two weeks. The nurse notes that the client remains weak with observable muscle atrophy. Which action should the nurse take?

Correct Answer is A

Explanation

A client is receiving metronidazole for Clostridium difficile pseudomembranous colitis. Which information should the nurse include in this client's medication teaching plan?

A young male athlete tells the nurse that he is concerned because his testicles seem to be shrinking. Which question is most important for the nurse to ask this client?

Patient Data Which possible side effects of fluticasone should the nurse advise the client about? Select all that apply.

The nurse mixes diphenhydramine 25 mg in a 100 mL bag of 0.9% sodium chloride, which is to be administered IV over 30 minutes. The IV pump should be set to administer how many mL/hour? (Enter numeric value only.)

Patient Data Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

The nurse is teaching a client with type 1 diabetes mellitus about the onset, peak, and duration of a new prescription for glargine insulin. If the insulin is self administered at 0800, when is the client most likely to experience hypoglycemia?

The client is receiving fentanyl transdermal patch 25 mcg/hr. Which nursing intervention is most important for the nurse to initiate?

Patient Data

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.