The health care provider prescribes scopolamine for a client who is planning to take cruise and is concerned about motion sickness. What information in the past medical history would serve as a contraindication for this medication?
Peptic ulcer
Asthma
Heart disease
Glaucoma
The Correct Answer is D
A) Peptic ulcer: Scopolamine is an anticholinergic medication that works by blocking acetylcholine, which can reduce nausea and motion sickness. While scopolamine can have anticholinergic effects that may slightly reduce gastric motility, it is not directly contraindicated in clients with a history of peptic ulcer. The medication does not significantly exacerbate the condition of peptic ulcers.
B) Asthma: While scopolamine can have anticholinergic effects that may lead to dry mouth and slight airway narrowing, it is not contraindicated in clients with asthma. However, the nurse should be cautious and monitor the client for any signs of respiratory distress, as anticholinergic medications can cause some bronchial smooth muscle relaxation, which could theoretically worsen asthma symptoms. It is not an absolute contraindication.
C) Heart disease: Scopolamine is not specifically contraindicated for individuals with heart disease, although caution should be used in patients with cardiovascular conditions due to its potential effects on heart rate and blood pressure. However, heart disease itself is not a direct contraindication for the use of scopolamine.
D) Glaucoma: Scopolamine is an anticholinergic medication, and anticholinergics can increase intraocular pressure. This is especially dangerous for clients with narrow-angle glaucoma, as the medication can exacerbate the condition, leading to a potential acute glaucoma attack. Therefore, individuals with a history of glaucoma, particularly narrow-angle glaucoma, should avoid scopolamine.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Evaluation: Evaluation is the phase where the nurse assesses whether the goals or outcomes of the care plan have been met. It involves determining if the interventions provided were effective in achieving the desired outcomes. In this scenario, the nurse is still
gathering information before the action is taken, so evaluation is not the correct phase.
B) Planning: Planning is the phase in the nursing process where the nurse develops a care plan, which includes setting goals and determining interventions based on the client's needs. Although reviewing the medical record and blood glucose level is important for planning the administration of insulin, this is more about gathering data rather than forming a plan of care.
C) Implementation: Implementation refers to the actual delivery of the nursing interventions or actions. In this case, administering the insulin would be part of the implementation phase, but reviewing the medical history and obtaining a fingerstick blood glucose reading are steps taken before implementing the medication.
D) Assessment: The nurse is collecting pertinent information about the client’s condition, including reviewing the medical record and obtaining the blood glucose level. Assessment is the first step in the nursing process and involves gathering information to help guide clinical decisions.
E) Diagnosis: Diagnosis is the phase in which the nurse analyzes the assessment data to identify the client’s health problems or potential risks. While the nurse is collecting data, the diagnosis comes after the assessment phase, when the nurse has enough information to make a clinical judgment about the client's health status.
Correct Answer is B
Explanation
A) Right dose: The right dose was administered. The order specifies 1000 mg of
acetaminophen, and the nurse gave 1000 mg. Therefore, the right dose was given, and this is not the issue in this situation.
B) Right route: The right route was not followed in this situation. The order specifies that acetaminophen should be administered IV, but the nurse administered the medication PO. The route of administration is crucial for ensuring the medication is delivered in the appropriate manner for the intended therapeutic effect. By giving the medication orally instead of intravenously, the nurse deviated from the prescribed route, which is a violation of the "right route."
C) Right reason: The right reason was followed because acetaminophen is commonly given for pain or fever management, and no information suggests the wrong reason for administering the drug. The nurse's action doesn’t indicate a mistake in the reasoning for giving the medication.
D) Right time: The right time is not affected here, as the nurse did administer the acetaminophen at the scheduled time. The issue is with the route, not the timing.
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