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. Increasing fluid intake may not alleviate the cramping and diarrhea, which are common side effects of magnesium citrate.
B. Abdominal cramping and diarrhea are expected side effects of magnesium citrate, and the patient can continue the medication unless symptoms become severe.
C. Discontinuing the medication should not be recommended unless the side effects are intolerable or the patient experiences severe reactions.
D. Switching to a different type of laxative is unnecessary unless the patient has contraindications to magnesium citrate or develops severe side effects.
Correct Answer is ["A","B"]
Explanation
A. The client's skin and eyes are visibly jaundiced is correct because jaundice indicates a buildup of bilirubin in the blood, which is a sign of liver dysfunction.
B. The client's AST and ALT levels are elevated is correct because elevated levels of these liver enzymes indicate hepatocellular injury, which is consistent with liver damage due to acetaminophen overdose.
C. The client's temperature is 102.5° F (39.2° C) is incorrect; while a fever can occur in various conditions, it is not specific for liver damage in this context.
D. The client has an elevated red blood cell count is incorrect; elevated red blood cell counts are not indicative of liver damage and may be related to other factors.
E. The client's eyes are sensitive to light is incorrect; photophobia is not a direct indicator of liver damage and is more related to other conditions.