Patient Data
The nurse is evaluating the client’s progress and nursing implementations. Bold the words to highlight the findings that would indicate the client has recovered from the adverse drug reaction.
1230: Shaking is lessened. Client is no longer flushed. No longer itching. Anxiety has decreased. Skin warm and dry. Heart rate 62 beats/minute, blood pressure 130/72 mm Hg. No chest pain noted. Respirations are even and unlabored. Drowsy.
Shaking is lessened.
Client is no longer flushed.
No longer itching.
Anxiety has decreased.
Skin warm and dry.
Heart rate 62 beats/minute, blood pressure 130/72 mm Hg.
No chest pain noted
Respirations are even and unlabored
Drowsy
The Correct Answer is ["A","B","C","D","E","F","G","H"]
Choice A reason:
Shaking is lessened: This indicates that the client’s nervous system is stabilizing. Shaking or tremors can be a sign of an adverse drug reaction, particularly if the reaction involves the central nervous system. The lessening of shaking suggests that the adverse effects are subsiding and the client’s condition is improving.
Choice B reason:
Client is no longer flushed: Flushing is a common symptom of an adverse drug reaction, particularly with medications like vancomycin, which can cause “red man syndrome.” The absence of flushing indicates that the reaction is resolving and the client’s skin is returning to its normal state.
Choice C reason:
No longer itching: Itching is a common symptom of an allergic reaction. The cessation of itching suggests that the histamine response is diminishing, indicating that the adverse reaction is being controlled and the client is recovering.
Choice D reason:
Anxiety has decreased: Anxiety can be a symptom of an adverse drug reaction, particularly if the reaction involves the cardiovascular or nervous system. The decrease in anxiety indicates that the client’s overall condition is stabilizing and that the adverse effects are subsiding.
Choice E reason:
Skin warm and dry: Normal skin temperature and moisture levels indicate that the client’s autonomic nervous system is functioning properly. This is a positive sign that the adverse drug reaction is resolving and the client’s body is returning to its normal state.
Choice F reason:
Heart rate 62 beats/minute, blood pressure 130/72 mm Hg: These vital signs are within normal ranges for a resting adult. A normal heart rate (60-100 beats per minute) and blood pressure (less than 120/80 mm Hg) indicate that the client’s cardiovascular system is stabilizing and that the adverse drug reaction is resolving.
Choice G reason:
No chest pain noted: The absence of chest pain is a positive sign, as chest pain can be a symptom of a severe adverse drug reaction, particularly if it involves the cardiovascular system. The lack of chest pain indicates that the client’s condition is improving.
Choice H reason:
Respirations are even and unlabored: Normal respiratory function indicates that the client’s respiratory system is not being adversely affected by the drug reaction. Even and unlabored respirations suggest that the client is recovering and that the adverse effects are subsiding.
Choice I reason:
Drowsy: While drowsiness can be a side effect of medications like diphenhydramine, it can also indicate that the client’s body is relaxing and recovering from the adverse drug reaction. Drowsiness in this context is a sign that the client is stabilizing and that the adverse effects are being managed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Avoiding crowds and people who are sick is crucial for clients taking methotrexate and adalimumab. Both medications suppress the immune system, increasing the risk of infections. Methotrexate is an immunosuppressant that can reduce the body’s ability to fight infections. Adalimumab, a TNF inhibitor, also lowers the immune response, making clients more susceptible to infections. Therefore, avoiding exposure to potential sources of infection is essential to prevent serious health complications.
Choice B reason:
While undergoing annual eye examinations is important for overall health, it is not directly related to the use of methotrexate and adalimumab. Methotrexate can cause ocular side effects, but these are relatively rare. Regular eye exams are a good practice but not the most critical instruction in this context.
Choice C reason:
Obtaining routine vaccinations is generally recommended for clients on immunosuppressive therapy. However, live vaccines should be avoided as they can cause infections in immunocompromised individuals. Non-live vaccines, such as the flu shot, are safe and should be administered according to the vaccination schedule. This instruction is important but secondary to avoiding exposure to infections.
Choice D reason:
Having a chest x-ray prior to the first dose of adalimumab is necessary to check for latent tuberculosis (TB). Adalimumab can reactivate latent TB, so screening is essential before starting the medication. However, this is a one-time requirement and not an ongoing instruction like avoiding crowds and sick people.
Correct Answer is C
Explanation
Choice A reason:
Counting the apical and radial pulses simultaneously can help detect pulse deficits, which may indicate cardiac issues. However, this is not the most critical assessment for a client receiving hydromorphone.
Choice B reason:
Observing for edema around the ankles is important for assessing fluid retention and potential heart failure. While relevant, it is not the primary concern for a client on hydromorphone.
Choice C reason:
Auscultating the client’s bowel sounds is crucial because hydromorphone, like other opioids, can cause constipation and potentially lead to paralytic ileus, a serious condition where the intestines stop moving food through. Monitoring bowel sounds helps detect early signs of this complication.
Choice D reason:
Measuring the client’s capillary glucose level is important for diabetic patients or those at risk of hyperglycemia. However, it is not directly related to the administration of hydromorphone.
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