Patient Data

Exhibits

Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.

Blood glucose 218 mg/dL (12.1 mmol/L)

Dizziness while sitting up

Blood pressure 162/111 mm Hg

Pain rated at 1 on a 0 to 10 scale

Urine output 600 mL

Answer and Explanation

The Correct Answer is {"A":{"answers":"C"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"C"}}

Blood glucose 218 mg/dL (12.1 mmol/L)

Classification: Unrelated Finding
Rationale: Minoxidil does not influence blood glucose levels. This elevated blood glucose is likely related to the patient’s known history of type 2 diabetes mellitus. It's not a side effect or intended therapeutic action of minoxidil.

Dizziness while sitting up

Classification: Nontherapeutic Side Effect
Rationale: Minoxidil is a vasodilator that can cause a rapid drop in blood pressure, particularly when changing positions (orthostatic hypotension). Dizziness is a common side effect due to decreased cerebral perfusion when blood pressure drops too quickly or too much.

Blood pressure 162/111 mm Hg

Classification: Therapeutic Result
Rationale: On admission, the patient’s BP was dangerously high at 203/166 mm Hg. A subsequent reading of 162/111 mm Hg shows a significant drop, indicating that minoxidil is having the desired therapeutic effect of lowering blood pressure, even though it's still above target.

Pain rated at 1 on a 0 to 10 scale

Classification: Unrelated Finding
Rationale: Minoxidil is not a pain medication and does not impact pain perception. A low pain score of 1 is likely due to an unrelated mild discomfort or pre-existing condition and has no connection to minoxidil's effects.

Urine output 600 mL

Classification: Unrelated Finding
Rationale: Minoxidil may cause fluid retention, but 600 mL urine output is within the normal range over a few hours (depending on timing and context). This measurement alone does not indicate a therapeutic or side effect of the drug, and without signs of oliguria or diuresis, it remains unrelated.

Nursing Test Bank

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Correct Answer is D

Explanation

A. Monitor urinary output: While monitoring output is important, it does not provide immediate diagnostic information regarding the cause of the client’s thirst. It is a supportive action but not the most efficient first step to investigate potential hyperglycemia.

B. Notify the healthcare provider (HCP): Notifying the HCP is appropriate if there are abnormal findings or the client’s condition worsens. However, the nurse should gather objective data—such as a blood glucose reading—before contacting the provider.

C. Prepare to give insulin: Insulin should not be administered without confirmation of elevated blood glucose. Giving insulin without verifying hyperglycemia could lead to serious complications, including hypoglycemia.

D. Obtain fingerstick blood glucose: Methylprednisolone, a corticosteroid, can raise blood glucose levels, and excessive thirst is a classic symptom of hyperglycemia. Checking the client’s blood glucose is the most appropriate first action to determine if elevated glucose is causing the symptom.

A. Document the client's refusal of the medication at this time. B. Explain the need to take the medication at least 1 hour before meals. C. Allow the client to take the medication up to 1 hour after breakfast. D. Instruct the client to take it when the meal tray is delivered.

Correct Answer is B

Explanation

A. Document the client's refusal of the medication at this time: While documentation is necessary if a medication is refused, the priority is to educate the client first. The nurse should explain the proper timing of sucralfate to promote understanding and adherence rather than simply accepting refusal.

B. Explain the need to take the medication at least 1 hour before meals: Sucralfate acts by forming a protective barrier over ulcerated mucosa and must be taken on an empty stomach for maximum effectiveness. Administering it one hour before meals ensures the stomach lining is properly coated before food intake.

C. Allow the client to take the medication up to 1 hour after breakfast: Taking sucralfate after a meal diminishes its ability to bind effectively to the mucosa. Food interferes with its action, so post-meal dosing is inappropriate for achieving therapeutic benefit.

D. Instruct the client to take it when the meal tray is delivered: Taking sucralfate at mealtime is too late for optimal therapeutic effect. At that point, gastric contents may interfere with its binding to ulcerated areas, reducing its protective action.

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Patient Data Exhibits Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is taking methylprednisolone reports feeling thirsty. Which action should the nurse take first?

Correct Answer is D

Explanation

The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?

Correct Answer is B

Explanation

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Patient Data

Exhibits

Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a nontherapeutic side effect, or an unrelated finding. Each row must have one option selected.