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 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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
- Cardiopulmonary arrest is not the immediate concern because the client remains hemodynamically stable with a spontaneous pulse and respiration, despite experiencing ventricular tachycardia. Arrest would be indicated by pulselessness, which has not yet occurred.
- Hypovolemic shock could be a differential due to vomiting and diarrhea; however, the hallmark features of severe tachycardia, headache, and ventricular arrhythmias are more consistent with systemic drug toxicity, especially in a client on theophylline.
- Allergic reaction is unlikely as there is no report of skin manifestations, airway inflammation, or anaphylaxis. The client’s symptoms of dizziness, gastrointestinal distress, and arrhythmias suggest a pharmacologic toxicity rather than hypersensitivity.
- Drug toxicity is the most probable diagnosis, given the client’s history of theophylline use, concurrent recent antibiotic therapy that may have impaired theophylline metabolism, and now presenting with ventricular tachycardia, headache, and severe gastrointestinal symptoms.
- Assess allergies would be a general precaution in medication reviews but is not a priority intervention in the acute management of suspected theophylline toxicity causing arrhythmias and systemic instability.
- Administer albuterol would worsen the clinical situation because it is a beta-agonist that increases heart rate and can precipitate more severe arrhythmias in a client already showing ventricular tachycardia.
- Hold theophylline is critical because continuing administration would exacerbate toxicity. Theophylline has a narrow therapeutic index, and symptoms indicate that blood levels are already dangerously elevated.
- Assess medication interactions is necessary because many antibiotics, particularly macrolides and quinolones, inhibit cytochrome P450 enzymes and can significantly increase theophylline levels, leading to toxicity.
- Give a bolus of IV fluids might address potential dehydration from vomiting and diarrhea; however, it would not directly correct the toxic arrhythmogenic effects currently threatening the client’s stability.
- Oxygen saturation should be maintained but is not the primary marker for guiding treatment of theophylline toxicity, which primarily manifests with cardiovascular and neurologic symptoms.
- Serum electrolyte levels are useful to assess contributing factors to arrhythmias, but in this situation, the priority is managing the toxic level of theophylline causing direct cardiac irritability.
- Respiratory rate should be monitored due to underlying asthma and potential respiratory distress, but changes in respiratory rate alone will not adequately reflect progression or improvement of systemic toxicity.
- Cardiac rhythm monitoring is essential because ventricular arrhythmias are life-threatening and are a major clinical feature of theophylline toxicity; immediate identification and management are critical.
- Theophylline blood levels must be urgently checked to confirm suspected toxicity, guide the need for interventions such as activated charcoal, and determine the severity of systemic drug accumulation.
Correct Answer is A
Explanation
A. Calcium 13.0 mg/dL (3.3 mmol/L): Alendronate is used to inhibit bone resorption and is typically prescribed when calcium levels are normal. A high calcium level suggests hypercalcemia, which could worsen if alendronate is given. Therefore, the medication should be withheld, and the healthcare provider must be notified for further evaluation.
B. Magnesium 2.4 mEq/L (2.4 mmol/L): This magnesium level is slightly elevated but is not critically abnormal. Magnesium levels are not a primary consideration when deciding whether to administer alendronate, and this finding alone would not necessitate withholding the medication.
C. Potassium 5.2 mEq/L (5.2 mmol/L): Mild hyperkalemia is noted here, but potassium levels do not directly impact the safety or effectiveness of alendronate. The nurse should monitor it but does not need to withhold alendronate based on this finding.
D. Sodium 132 mEq/L (132 mmol/L): This value indicates mild hyponatremia, but sodium abnormalities are not a direct contraindication to alendronate therapy. The medication could still be administered while addressing the sodium imbalance separately.
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