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 D
Explanation
A. The patient’s statement about the peak of NPH insulin being 6-12 hours is correct; it is important to know when to monitor for hypoglycemia.
B. Taking NPH before breakfast is appropriate, as it is typically given in the morning to provide coverage for meals throughout the day.
C. The duration of NPH insulin lasting for 12-18 hours is accurate, which is crucial for understanding how long the patient can expect blood glucose control.
D. NPH insulin should not be taken right before meals as it does not act quickly enough to cover immediate carbohydrate intake. Rapid-acting insulin is typically used for that purpose, indicating a need for further teaching.