The nurse is caring for a client who experienced a severe headache. When the prescribed dose of analgesics did not cause relief, the client took double the dosage 1 hour later. The nurse should assess the client for what adverse effect?
An allergic reaction
Anaphylactic reaction
Poisoning
Sedative effects
The Correct Answer is C
A. An allergic reaction is a possible response to medication, but it is not directly related to doubling the dosage.
B. Anaphylactic reaction is a severe and rapid allergic response; while possible, it is not the most likely consequence of an overdose in this context.
C. Poisoning is a likely concern when a client takes double the prescribed dosage of analgesics, especially if the medication has a narrow therapeutic index or is known to cause toxicity at high doses.
D. Sedative effects could occur depending on the analgesic used, but poisoning is a more pressing concern following an overdose.
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Correct Answer is B
Explanation
A. Performing a blood sugar analysis is important, but the immediate symptoms indicate hypoglycemia, and rapid treatment is necessary before confirming blood sugar levels.
B. Having the client drink a glass of orange juice provides a quick source of glucose to counteract hypoglycemia, which is the most appropriate initial response to address the client's symptoms.
C. Administering 1 ampule of 50% dextrose intravenously is an appropriate intervention for severe hypoglycemia but is not the initial step for a client who can still take oral carbohydrates.
D. Administering insulin would worsen the client's condition by lowering blood sugar levels further, which is not indicated in this scenario.
Correct Answer is ["B","C","D"]
Explanation
A. Sit up comfortably in the bed is incorrect; the client should be in an upright position, which can be done while sitting up comfortably, but it’s essential to emphasize a more upright posture for optimal administration.
B. Tilt the head slightly to the side is correct; this position helps facilitate the delivery of the medication into the nasal passages.
C. Insert the tip of the nose piece into one nostril is correct; proper insertion ensures effective delivery of the medication.
D. Hold the breath for a few seconds after administering the spray is correct; this allows the medication to be absorbed more effectively.
E. Blow the nose 1 minute after administering the spray is incorrect; clients should avoid blowing their nose immediately after use to allow for proper absorption of the medication.