Nokea
A client has been receiving an aminoglycoside for several weeks and comes to the clinic complaining of ringing in his ears and some dizziness. The nurse suspects ototoxicity. When developing this client's plan of care, which nursing diagnosis would be the priority?
- A. Impaired Comfort
- B. Altered Thought Process
- C. Diarrhea
- D. Risk for Injury
Correct Answer: D
Rationale: The development of ototoxicity would lead the nurse to identify a nursing diagnosis of Risk for Injury related to the effects of ototoxicity. Although the client's ringing in the ears could cause discomfort, the priority nursing diagnosis would be Risk for Injury. There is no evidence of impaired comfort, altered thought process or diarrhea.
You may also like to solve these questions
A patient is to receive tetracycline therapy at home. After teaching the patient about foods to avoid when taking the drug, the nurse determines that the teaching was successful when the patient states he will avoid which of the following? Select all that apply.
- A. Yogurt
- B. Cheese
- C. Calcium-fortified cereals
- D. Citrus fruits
Correct Answer: A, B, C
Rationale: The patient should avoid dairy products including yogurt, cheese, milk, cream, ice cream, ice milk, or frozen custard before or after taking tetracycline. Citrus fruits and green leafy vegetables should not be avoided.
A patient is prescribed demeclocycline. The nurse would teach the patient to be alert for signs of which of the following?
- A. Photosensitivity
- B. Abdominal pain
- C. Cramping
- D. Blood dyscrasias
Correct Answer: A
Rationale: Demeclocycline causes photosensitivity reactions. Abdominal pain and cramping are adverse reactions of macrolides. Blood dyscrasias are an adverse reaction of lincosamides.
A group of nursing students are reviewing information about aminoglycosides. The students demonstrate understanding when they identify which of the following as an example? Select all that apply.
- A. Amikacin (Amikin)
- B. Amoxicillin (Amoxil)
- C. Kanamycin (Kantrex)
- D. None of the above
Correct Answer: A
Rationale: The aminoglycosides include amikacin, gentamicin, kanamycin, neomycin, streptomycin, and tobramycin. Amoxicillin is an aminopenicillin. Vancomycin is a miscellaneous agent that disrupts the bacterial cell wall. Azithromycin is classified as a macrolide.
A nurse is reading a journal article about spectinomycin. Which of the following would the nurse expect to find as being discussed about this drug? Select all that apply.
- A. Spectinomycin is used to treat chlamydia infections.
- B. Spectinomycin is used to treat gonorrhea infections.
- C. Spectinomycin is chemically unrelated to aminoglycosides.
- D. Spectinomycin can be used in clients with penicillin allergy.
Correct Answer: B, D, E
Rationale: Spectinomycin is used to treat gonorrhea infections in clients who are allergic to penicillins, cephalosporins, or probenecid (Benemid). Spectinomycin is chemically related to but different from aminoglycosides. No significant drug or food interactions for spectinomycin are known.
The nurse is completing an ongoing assessment of a client receiving erythromycin. The nurse would notify the primary health care provider immediately if assessment reveals which of the following? Select all that apply.
- A. Significant drop in blood pressure
- B. Increase in heart rate
- C. Decrease in temperature
- D. Increase in respiratory rate
Correct Answer: A, B, D, E
Rationale: During ongoing assessment of a client receiving erythromycin, the nurse should notify the primary health care provider immediately if the client has a significant drop in blood pressure, increase in heart rate, increase in respiratory rate, or sudden increase in temperature.