NURSING 201 Focus on Adult Health_NURS 201 Adult Health Assessment.
⦁ ID: 4 ⦁ A nurse is monitoring a client who is taking spironolactone for the treatment of hypertension. Which findings denote adverse effects of the medication? Select all that apply. ⦁ Constipation ⦁ Tall T waves Correct ⦁ Hyporeflexia ⦁ Shallow respirations ⦁ Prolonged PR interval Correct ⦁ Hyperactive bowel sounds Correct ⦁ Rationale: Spironolactone is a potassium-sparing diuretic. Potassium-sparing diuretics can cause hyperkalemia. Cardiovascular manifestations of hyperkalemia include tall T waves, widened QRS complexes, prolonged PR intervals, and flat P waves. Other cardiovascular manifestations include an irregular heart rate, decreased blood pressure, and ectopic heartbeats. Muscle twitches occur in hyperkalemia. Hyperactive bowel sounds and diarrhea also occur in hyperkalemia. Constipation, hyporeflexia, and shallow respirations are signs of hypokalemia. ⦁ Test-Taking Strategy: The knowledge that spironolactone is a potassium-sparing diuretic will assist you in determining that hyperkalemia is an adverse effect of the medication. Recalling the manifestations of hyperkalemia will direct you to the correct options. Also, note that the incorrect options are comparable or alike in that they indicate a slowed body response or function. Review the adverse effects of spironolactone and the manifestations of hyperkalemia if you had difficulty with this question. ⦁ Level of Cognitive Ability: Analyzing ⦁ Client Needs: Physiological Integrity ⦁ Integrated Process: Nursing Process/Assessment ⦁ Content Area: Adult Pharmacology ⦁ Giddens Concepts: Clinical Judgment, Fluid and Electrolytes ⦁ HESI Concepts: Clinical Decision-Making/Clinical Judgment, Fluids and Electrolytes ⦁ Reference: Hodgson, B., & Kizior, R. (2015). Saunders nursing drug handbook 2015. (pp. ) St. Louis: Saunders. ⦁ Awarded 3.0 points out of 3.0 possible points. ⦁ 2.ID: 8 ⦁ A nurse is providing dietary instructions to a client with chronic obstructive pulmonary disease (COPD) who is experiencing a loss of appetite and complains of feeling “too full to eat.” What does the nurse encourage the client to do? Select all that apply. ⦁ Avoid drinking fluids before and during meals Correct ⦁ Eat a variety of dark-green vegetables, such as broccoli ⦁ Have snacks, such as crackers and cheese, between meals ⦁ Select foods that are easy to chew and are not gas forming Correct ⦁ Consume high-calorie drinks, such as milkshakes, between meals
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