When administering zolpidem to an older client, which computer documentation indicates that the desired outcome has been achieved?

Sleeps soundly through the night.

Decreased episodes of incontinence.

Improved ability to concentrate.

Exhibits fewer emotional outbursts.

Answer and Explanation

The Correct Answer is A

Choice A reason: Sleeping soundly through the night is the desired outcome of administering zolpidem, which is a sedative-hypnotic that induces sleep by enhancing the activity of GABA, an inhibitory neurotransmitter. Zolpidem is used to treat insomnia, especially difficulty falling asleep.

Choice B reason: Decreasing episodes of incontinence is not a relevant outcome of administering zolpidem, which does not affect urinary function or bladder control. Incontinence may be caused by other factors, such as aging, prostate problems, or urinary tract infections.

Choice C reason: Improving ability to concentrate is not a pertinent outcome of administering zolpidem, which does not affect cognitive function or attention span. Zolpidem may actually impair memory and cause daytime drowsiness or confusion in some patients.

Choice D reason: Exhibiting fewer emotional outbursts is not a significant outcome of administering zolpidem, which does not affect mood or behavior. Zolpidem may actually cause paradoxical reactions, such as agitation, aggression, or hallucinations in some patients.

: [Zolpidem (Oral Route)]

: [Insomnia]

: [Urinary Incontinence]

: [Concentration Problems]

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Correct Answer is A

Explanation

Choice A reason: Apical pulse rate of 50 beats/minute requires nursing intervention prior to the administration of digoxin, which is a medication that slows down and strengthens the heartbeat. Digoxin can cause bradycardia, which is a slow heart rate below 60 beats/minute. Bradycardia can lead to inadequate blood flow and oxygen delivery to the body. The nurse should withhold the dose of digoxin and notify the prescriber if the apical pulse rate is below 60 beats/minute.

Choice B reason: Irregular apical pulse rhythm does not require nursing intervention prior to the administration of digoxin, which is a medication that treats arrhythmias, which are irregular heart rhythms. Digoxin can correct or prevent some types of arrhythmias, such as atrial fibrillation or flutter. The nurse should monitor the apical pulse rhythm and report any changes to the prescriber, but it is not a reason to withhold the dose of digoxin.

Choice C reason: Presence of a systolic heart murmur does not require nursing intervention prior to the administration of digoxin, which is a medication that improves the pumping function of the heart. A systolic heart murmur is a sound that occurs when the heart contracts and blood flows through a narrow or leaky valve. Digoxin can reduce the symptoms of heart failure, such as shortness of breath, fatigue, and edema, which may be associated with a systolic heart murmur. The nurse should document the presence and characteristics of the heart murmur, but it is not a reason to withhold the dose of digoxin.

Choice D reason: Apical pulse heard best at the pulmonic site does not require nursing intervention prior to the administration of digoxin, which is a medication that affects the electrical activity and contractility of the heart. The apical pulse is the heartbeat heard at the apex of the heart, which is located at the fifth intercostal space on the left midclavicular line. The pulmonic site is located at the second intercostal space on the left sternal border, where the sound of blood flow through the pulmonary valve can be heard. The nurse should listen to the apical pulse at the correct location, but it is not a reason to withhold the dose of digoxin.

A. Seizures B. Nausea C. Orthostatic hypotension D. Sedation E. Euphoria F. Itching G. Urinary retention

Correct Answer is ["B","C","D"]

Explanation

Choice A reason:

Seizures are not a common side effect of morphine, and they are unlikely to contribute to this client's fall risk. Seizures can occur in rare cases of morphine overdose, hypersensitivity, or withdrawal, but they are not expected in a client who is receiving a continuous and monitored dose of morphine. Therefore, choice A is incorrect.

Choice B reason:

Nausea is a common side effect of morphine, and it can contribute to this client's fall risk. Nausea can cause the client to feel dizzy, weak, or unsteady, and it can also impair the client's appetite and hydration status. Nausea can also trigger vomiting, which can increase the risk of aspiration or dehydration. Therefore, choice B is correct.

Choice C reason:

Orthostatic hypotension is a common side effect of morphine, and it can contribute to this client's fall risk. Orthostatic hypotension is a sudden drop in blood pressure that occurs when the client changes position from lying to sitting or standing. Orthostatic hypotension can cause the client to feel faint, dizzy, or lightheaded, and it can also increase the risk of syncope (loss of consciousness) or cardiac arrhythmias. Therefore, choice C is correct.

Choice D reason:

Sedation is a common side effect of morphine, and it can contribute to this client's fall risk. Sedation can cause the client to feel sleepy, drowsy, or confused, and it can also impair the client's alertness and coordination. Sedation can also reduce the client's ability to respond to stimuli or alarms, and it can increase the risk of respiratory depression or coma. Therefore, choice D is correct.

Choice E reason:

Euphoria is a common side effect of morphine, and it can contribute to this client's fall risk. Euphoria is a feeling of intense happiness or well-being that is induced by the activation of opioid receptors in the brain. Euphoria can cause the client to feel overconfident, impulsive, or reckless, and it can also impair the client's judgment and perception of reality. Euphoria can also increase the risk of psychological dependence or addiction. Therefore, choice E is correct.

Choice F reason:

Itching is a common side effect of morphine, and it can contribute to this client's fall risk. Itching is caused by the release of histamine from mast cells in response to the stimulation of opioid receptors in the skin. Itching can cause the client to scratch excessively, which can damage the skin and increase the risk of infection. Itching can also distract the client from other sensations or warnings, and it can reduce the client's comfort and quality of life. Therefore, choice F is correct.

Choice G reason:

Urinary retention is a common side effect of morphine, and it can contribute to this client's fall risk. Urinary retention is the inability to empty the bladder completely or voluntarily due to the inhibition of bladder contraction by opioid receptors in the urinary tract. Urinary retention can cause the client to feel pain, discomfort, or urgency in the lower abdomen, and it can also increase the risk of urinary tract infection or kidney damage. Urinary retention can also prompt the client to attempt to get out of bed without assistance or supervision, which can increase the risk of falling. Therefore, choice G is correct.

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When administering zolpidem to an older client, which computer documentation indicates that the desired outcome has been achieved?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding requires nursing intervention prior to the administration of a prescribed dose of digoxin to an adult?

Correct Answer is A

Explanation

Patient Data Exhibits The charge nurse places a fall precautions sign on the client's door. What side effects of morphine could contribute to this client's fall risk? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

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