Which is the priority action by the nurse when a patient discloses a medication allergy during the health history before a surgical procedure?
Verifying the information with the patient's family members at the bedside
Placing an alert bracelet on the patient before leaving the unit
Asking the patient to describe the reaction that occurs
Documenting the information on the patient's medical record
The Correct Answer is C
A. Verifying the information with the patient's family members at the bedside: While family members can provide insight, the most critical step is gathering information directly from the patient about the reaction.
B. Placing an alert bracelet on the patient before leaving the unit: While this is necessary, the nurse should first confirm the details of the allergy.
C. Asking the patient to describe the reaction that occurs: The nurse must determine whether the reaction is a true allergy (e.g., anaphylaxis, rash, difficulty breathing) or an intolerance (e.g., nausea, drowsiness). This ensures appropriate precautions are taken.
D. Documenting the information on the patient's medical record: Documentation is crucial but should follow verification of the allergy details.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Postpartum depression: Postpartum depression occurs after childbirth, not before menstruation.
B. Bipolar disorder: Bipolar disorder involves mood swings between mania and depression that are not tied to the menstrual cycle.
C. Premenstrual dysphoric disorder (PMDD): PMDD is a severe form of premenstrual syndrome (PMS) characterized by significant mood disturbances, such as depression, irritability, and anxiety, occurring in the luteal phase (one week before menstruation).
D. Cyclothymic disorder: Cyclothymic disorder is a chronic mood disorder involving frequent mood fluctuations but is not related to the menstrual cycle.
Correct Answer is D
Explanation
A. Educate the patient about the time period before new medications become effective. Education is important but not the priority in a crisis situation. Immediate safety is the top concern.
B. Have the client verbalize their plans for discharge. This is a future-oriented intervention, but the priority is ensuring the client's safety now.
C. Encouraging the client to participate in group therapy. Group therapy is beneficial but does not take precedence over ensuring immediate safety.
D. Monitor the client closely but at random intervals. Patients with suicidal ideation require close monitoring to prevent self-harm. Observing at random intervals reduces the chance of the patient anticipating when they are not being watched.
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