Patient data
Complete the diagram by dragging from the choices below to specify 1 potential condition the client is most likely experiencing, 2 actions the nurse would take to address that condition, and 2 parameters the nurse would monitor to assess the client's progress.
The Correct Answer is []
Cerebral edema is the most likely condition the client is experiencing based on the history of submersion, subsequent resuscitation, and the finding of brain edema noted on the head CT scan.
Implementing seizure precautions is essential because cerebral edema can increase the risk of seizures. Discontinuing the 0.9% sodium chloride solution IV infusion is necessary because hyponatremia (low serum sodium) is associated with cerebral edema, and reducing fluid intake can help manage cerebral edema.
Monitoring strict intake and output is crucial to assess the client's fluid balance and ensure that any changes in fluid status are promptly addressed. Monitoring neurologic status is vital for detecting any changes in consciousness, responsiveness, or neurological function, which could indicate worsening cerebral edema or neurological complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Monitoring for changes in stool color is important because itraconazole can rarely cause liver toxicity, which may manifest as changes in stool color (e.g., clay-colored stools). This statement demonstrates the client's understanding of the need for monitoring for potential adverse effects.
B. Taking itraconazole with antacids is incorrect because antacids can reduce the absorption of itraconazole. This statement requires correction by the nurse as it could potentially decrease the effectiveness of the medication.
C. Drinking grapefruit juice can increase the effects of itraconazole by inhibiting its metabolism, leading to higher blood levels of the medication. Therefore, this statement is incorrect and requires correction.
D. Reporting any difficulty with breathing is important as itraconazole can rarely cause severe allergic reactions or respiratory side effects. This statement demonstrates the client's
understanding of the need to report any concerning symptoms.
Correct Answer is ["B","E"]
Explanation
A. Blood urea nitrogen (BUN) is not typically monitored to evaluate the effectiveness of antibiotics in treating respiratory tract infections. It is more commonly monitored to assess renal function and hydration status.
B. White blood cell (WBC count is monitored to evaluate the body's response to infection and the effectiveness of antibiotic therapy. A decrease in the WBC count can indicate resolution of the infection.
C. Red blood cell (RBC count is not directly related to the evaluation of antibiotic effectiveness in treating respiratory tract infections.
D. Urinalysis is not typically monitored to evaluate the effectiveness of antibiotics in treating respiratory tract infections unless there are specific indications of urinary tract involvement.
E. Sputum culture and sensitivity testing is important to identify the causative organism of the respiratory tract infection and determine its susceptibility to antibiotics. Monitoring the results of sputum culture and sensitivity helps ensure appropriate antibiotic selection.
F. Serum potassium levels may be monitored for clients receiving certain antibiotics, such as some types of penicillins or fluoroquinolones, due to the potential for electrolyte disturbances.
However, it is not a direct measure of antibiotic effectiveness in treating respiratory tract infections.
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