Which of these findings, from a client taking steroids, should the nurse report immediately?
Temperature of 101.2 degrees Fahrenheit
Blood pressure of 144/68 mm Hg
Glucose 128 mg/dl
Heart rate of 102 beats per minute
The Correct Answer is A
a) An elevated temperature could indicate an infection, which is a serious concern in a client taking steroids, as steroids can suppress the immune system. This finding should be reported immediately.
b) Blood pressure within this range is generally acceptable and may not be a cause for immediate concern.
c) A glucose level of 128 mg/dl is within a reasonable range and may not require immediate reporting unless there are other concerning factors.
d) A heart rate of 102 beats per minute is generally within an acceptable range and may not be an immediate cause for concern in the absence of other symptoms.
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Related Questions
Correct Answer is B
Explanation
a) Vitamin D levels may be affected by long-term glucocorticoid use, but the described symptoms are more indicative of potential glucocorticoid-related side effects, such as Cushingoid features, which warrant liver function tests.
b) Liver function tests are appropriate to assess the impact of long-term glucocorticoid use on the liver, as these medications can affect liver function.
c) Serum electrolytes are important to monitor, but the specific symptoms mentioned (full cheeks, hump of fat) are not typically associated with electrolyte imbalances.
d) A tuberculin skin test is unrelated to the observed symptoms and is not typically ordered based on the physical features described.
Correct Answer is D
Explanation
a) While discussing possible opiate dependence is important, the immediate concern is the client's respiratory depression and altered level of consciousness, which may require naloxone administration.
b) Noting the effectiveness of analgesia is relevant but does not address the current respiratory depression and lethargy observed in the client.
c) Encouraging the client to turn over and cough may not be effective in addressing severe respiratory depression, and immediate intervention is needed.
d) The client's symptoms, including drowsiness, lethargy, pinpoint pupils, and respiratory depression, are consistent with opioid overdose. Naloxone is the antidote for opioid toxicity and should be administered promptly.
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