A nurse is collecting data from a client who has heart failure prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?
Blood pressure of 80/40 mm/Hg
Oxygen saturation of 95%
Serum sodium level of 140 mEq/L
Serum potassium level of 4.8 mEq/L
The Correct Answer is A
A. A blood pressure of 80/40 mm/Hg indicates hypotension, which is a contraindication for administering furosemide. The medication can further lower blood pressure and increase the risk of adverse effects.
B. An oxygen saturation of 95% is within normal limits and does not indicate a need to withhold furosemide.
C. A serum sodium level of 140 mEq/L is normal and would not warrant withholding the medication.
D. A serum potassium level of 4.8 mEq/L is also normal and safe for furosemide administration, as the medication may cause potassium loss but does not require withholding if the level is within range.
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Correct Answer is A
Explanation
A. Computerized tomography angiography (CTA) is commonly used to visualize blood vessels and identify any blockages or abnormalities in blood flow that may have contributed to a TIA.
B. While a complete blood count (CBC) may be ordered as part of the general assessment, it is not specific for diagnosing TIA and does not provide information on cerebrovascular issues.
C. A transesophageal echocardiogram (TEE) is used to assess cardiac function and may be indicated in some stroke cases, but it is not the primary diagnostic test for TIA.
D. Prothrombin time (PT) assesses clotting function but is not specific for diagnosing TIA; it may be ordered for other reasons but is not a primary diagnostic tool in this context.
Correct Answer is ["A","B","D"]
Explanation
A. Pain behind the ear is a common early symptom of Bell's palsy due to inflammation of the facial nerve.
B. Muscle distortion occurs as the facial muscles on the affected side weaken or become paralyzed, leading to an asymmetrical appearance.
C. Facial twitching is not a common manifestation of Bell's palsy; rather, it involves muscle paralysis or weakness.
D. Impaired taste, especially in the anterior two-thirds of the tongue, can occur due to facial nerve involvement.
E. Hearing loss is not typically associated with Bell's palsy; it usually affects facial motorfunction, not auditory function.