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When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

Administer a prescribed antianxiolytic.

Allow the client to rest before taking the vital signs.

Notify the client representative.

Offer the client hot tea to promote relaxation.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Administering an antianxiolytic might be premature and should only be done if prescribed and necessary.

B. Allowing the client to rest before taking vital signs helps ensure that the measurements are accurate and not influenced by recent emotional distress.

C. Notifying the client representative might be relevant later, but addressing the client's immediate needs and emotional state is the priority.

D. Offering hot tea may not be appropriate in this situation and does not directly address the need for accurate vital signs.

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A. Acetaminophen. B. Captopril. C. Omeprazole. D. Prednisone.

Correct Answer is A

Explanation

Rationale:

A. Acetaminophen, especially in high doses or with prolonged use, is known to cause hepatotoxicity, which can lead to jaundice. Notifying the healthcare provider is crucial to prevent further liver damage.

B. Captopril, an ACE inhibitor used for hypertension, is not commonly associated with jaundice or liver dysfunction.

C. Omeprazole, a proton pump inhibitor used for GERD, is less likely to cause liver damage compared to acetaminophen.

D. Prednisone, a corticosteroid, can have many side effects, but hepatotoxicity is not among the most common, making acetaminophen the most concerning drug in this context.

A. Hypertension. B. Peripheral edema. C. Gingival hyperplasia. D. Hematuria.

Correct Answer is C

Explanation

Rationale:

A. Hypertension is not a common side effect of phenytoin. It is not typically associated with the medication.

B. Peripheral edema is not commonly linked to phenytoin use.

C. Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin, particularly with long-term use.

D. Hematuria is not a typical side effect of phenytoin and may indicate a different medical issue.

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When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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Take full exam for free When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

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Correct Answer is A

Explanation

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When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?