Which finding in a client diagnosed with obstructive sleep apnea (OSA) would require a nurse to take immediate action?
Client difficult to arouse.
Blood pressure 142/92 mmHg.
Apneic periods lasting more than 10 seconds.
Oxygen desaturation to 90% when asleep.
The Correct Answer is A
This is because a client with obstructive sleep apnea (OSA) may have periods of apnea lasting more than 10 seconds during sleep, which can lead to hypoxia and hypercapnia. These conditions can cause the client to be difficult to arouse and may indicate respiratory failure.
The nurse should take immediate action to stimulate the client, provide oxygen, and call for help.
Choice B is wrong because blood pressure 142/92 mmHg is not an emergency for a client with OSA. It is within the stage 1 hypertension range, which may be caused by OSA or other factors. The nurse should monitor the client’s blood pressure and encourage lifestyle modifications, such as weight loss, exercise, and dietary changes.
Choice C is wrong because apneic periods lasting more than 10 seconds are expected in a client with OSA. This is the criterion for diagnosing OSA during a sleep study. The nurse should educate the client about the use of continuous positive airway pressure (CPAP) or other treatments to prevent apnea and improve oxygenation during sleep.
Choice D is wrong because oxygen desaturation to 90% when asleep is not an emergency for a client with OSA. It is a common finding in OSA due to the intermittent obstruction of the upper airway. The nurse should ensure that the client has supplemental oxygen available and teach the client about the benefits of CPAP or other devices to maintain airway patency and oxygen saturation during sleep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.
Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.
Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.
Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.
Correct Answer is A
Explanation
This statement suggests that the client needs further teaching because haloperidol is a medication that needs to be taken regularly and consistently to prevent relapse of symptoms related to schizophrenia. Stopping the medication abruptly can cause withdrawal effects and worsen the condition.
Choice B is wrong because it shows that the client understands the potential interaction between alcohol and haloperidol, which can increase the risk of sedation, drowsiness, and low blood pressure.
Choice C is wrong because it indicates that the client has realistic expectations about the onset of action of haloperidol, which can take several days or weeks to show improvement of symptoms.
Choice D is wrong because it demonstrates that the client is aware of the possible side effect of photosensitivity caused by haloperidol, which can make the skin more prone to sunburn and damage.
Haloperidol is an antipsychotic drug that works by blocking dopamine receptors in the brain. It is used to treat symptoms such as hallucinations, delusions, paranoia, and disorganized thinking in schizophrenia and other psychotic disorders. The normal dosage range for haloperidol is 0.5 to 20 mg per day, depending on the severity of the condition and the response to treatment. Some of the common side effects of haloperidol include extrapyramidal symptoms (EPS), such as muscle stiffness, tremors, restlessness, and abnormal movements; neuroleptic malignant syndrome (NMS), which is a rare but serious condition characterized by fever, muscle rigidity, altered mental status, and autonomic instability; and tardive dyskinesia (TD), which is a chronic movement disorder that involves involuntary movements of the tongue, lips, face, and limbs. Haloperidol can also cause weight gain, dry mouth, blurred vision, constipation, dizziness, insomnia, and sexual dysfunction.
Haloperidol should be used with caution in patients with cardiovascular disease, liver disease, seizure disorder, diabetes mellitus, thyroid dysfunction
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