Which adverse effects associated with levodopa therapy would support the nursing diagnosis Risk for Injury?

Orthostatic hypotension

Nausea and vomiting

Anorexia and depression

Tachycardia and palpitations

Answer and Explanation

The Correct Answer is A

A. Orthostatic hypotension:

Orthostatic hypotension, a sudden drop in blood pressure when standing up, is a potential adverse effect of levodopa therapy. This can lead to dizziness and increase the risk of falls, thus supporting the nursing diagnosis Risk for Injury.

B. Nausea and vomiting:

Nausea and vomiting are common side effects of levodopa therapy. While they can cause discomfort and dehydration, they are less directly related to the risk of physical injury compared to orthostatic hypotension.

C. Anorexia and depression:

Anorexia (loss of appetite) and depression can occur as adverse effects of levodopa therapy. While they can affect the patient's overall well-being and quality of life, they are not directly associated with an increased risk of physical injury.

D. Tachycardia and palpitations:

Tachycardia (rapid heart rate) and palpitations are less common adverse effects of levodopa therapy. While they may indicate cardiovascular issues, they are not typically associated with a direct risk of physical injury.

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Correct Answer is A

Explanation

A. Withhold the next dose and notify the physician:

Withholding the next dose of the cholinergic agent is the appropriate immediate action because the presence of inspiratory and expiratory wheezing bilaterally suggests bronchoconstriction or bronchospasm, which can be a serious adverse reaction to the medication. Notifying the physician promptly allows for further assessment and management of the patient's respiratory symptoms. The physician may need to adjust the medication regimen, order diagnostic tests, or provide treatment for bronchoconstriction.

B. Give the next dose:

Administering the next dose of the cholinergic agent could worsen the patient's respiratory symptoms and exacerbate bronchoconstriction. This action is contraindicated in the presence of wheezing, as it may further compromise the patient's respiratory function.

C. Assess heart rate:

While assessing heart rate is an important aspect of patient assessment, it is not the priority in this scenario. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing is a respiratory symptom that suggests airway obstruction, and immediate intervention is necessary to ensure adequate oxygenation and ventilation.

D. Assess blood pressure:

Similarly, while assessing blood pressure is important in patient care, it is not the priority in this situation. The priority is to address the respiratory distress and potential bronchoconstriction associated with the cholinergic agent. Wheezing indicates respiratory compromise, and prompt action is required to prevent further respiratory deterioration.

A. toes turning up and spreading B. downward curl of the toes C. pain in the big toe D. big toe bending upward

Correct Answer is A

Explanation

A. Toes turning up and spreading:

This description corresponds to the abnormal finding in the Babinski reflex. In a positive Babinski sign, the big toe (hallux) dorsiflexes (turns upward) and the other toes fan out. This response is abnormal in adults but normal in infants up to a certain age.

B. Downward curl of the toes:

This response is typical of the normal plantar reflex, where the toes curl downward (plantar flexion) in response to stimulation of the sole of the foot. It is not indicative of the Babinski reflex.

C. Pain in the big toe:

Pain in the big toe is not a characteristic finding of the Babinski reflex. The Babinski sign is assessed by observing the movement pattern of the toes in response to stimulation, rather than eliciting pain.

D. Big toe bending upward:

The big toe bending upward, or dorsiflexion of the big toe, is a specific component of the positive Babinski sign. However, it is typically accompanied by spreading of the other toes, which is the hallmark feature of the Babinski reflex.

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Which adverse effects associated with levodopa therapy would support the nursing diagnosis Risk for Injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient taking a cholinergic agent. When auscultating lung sounds, the nurse notes inspiratory and expiratory wheezing bilaterally. The best action for the nurse to take would be to:

Correct Answer is A

Explanation

The nurse documents an abnormal finding from the Babinski reflex as a (the):

Correct Answer is A

Explanation

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