Nokea
When assessing an older client who is receiving an antihistamine, the nurse integrates knowledge of which of the following as contributing to the client's higher risk of injury? Select all that apply.
- A. Hearing loss
- B. Steady gait
- C. Visual impairment
- D. Hypertension
- E. Diabetes
Correct Answer: A,C
Rationale: Older adult clients are more likely to experience injury from dizziness because with age comes an increased risk for falls due to sensorimotor deficits (hearing loss, visual impairment) or unsteady gait.
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The nurse would be especially alert for the development of which of the following when administering an antihistamine to an older adult? Select all that apply.
- A. Hypotension
- B. Hypertension
- C. Dry mouth
- D. Insomnia
- E. Sedation
Correct Answer: A,C,E
Rationale: Older adult clients are more likely to experience anticholinergic effects (dry mouth), dizziness, sedation, hypotension, and confusion while taking an antihistamine.
A 21-year-old client complains of a mild stinging sensation on using a nasal spray decongestant. Which response by the nurse would be most appropriate?
- A. You need to stop the medication immediately.
- B. The dose is probably too strong and needs to be reduced.
- C. This sensation is common and usually disappears with continued use.
- D. We better contact your primary health care provider right away.
Correct Answer: C
Rationale: The nurse needs to assure the client that the mild stinging sensation usually disappears with continued use. The drug needs to be stopped only if the stinging sensation is severe. The dose of the medication does not need to be altered. The primary health care provider does not need to be consulted immediately in the presence of a mild stinging sensation.
After teaching a group of nursing students about antihistamines, the instructor determines that the teaching was successful when the students identify which of the following as less sedating? Select all that apply.
- A. Loratadine (Claritin)
- B. Fexofenadine (Allegra)
- C. Cetirizine (Zyrtec)
- D. Brompheniramine (Lodrane)
- E. Clemastine (Tavist)
Correct Answer: A,B,C
Rationale: Loratadine, fexofenadine, and cetirizine are considered second-generation antihistamines that are less sedating than first-generation antihistamines (brompheniramine and clemastine).
The nurse understands that codeine-containing antitussives should be used cautiously in clients with which of the following conditions? Select all that apply.
- A. Pregnancy
- B. Convulsive disorders
- C. Prostatic hypertrophy
- D. Hyperlipidemia
- E. Type 2 diabetes
Correct Answer: A,B,C
Rationale: Codeine-containing antitussives should be used cautiously during pregnancy and labor and in clients with COPD, acute asthma attacks, pre-existing respiratory disorders, acute abdominal conditions, head injury, increased intracranial pressure, convulsive disorders, hepatic or renal impairment, and prostatic hypertrophy.
The nurse is preparing to administer a drug that acts by reducing the swelling in the nasal passages by vasoconstriction. Which of the following might the nurse be administering? Select all that apply.
- A. Loratadine
- B. Guaifenesin
- C. Dextromethorphan
- D. Phenylephrine
- E. Oxymetazoline
Correct Answer: D,E
Rationale: Phenylephrine and oxymetazoline are decongestants that reduce swelling in the nasal passages by vasoconstriction. Loratadine is an antihistamine, guaifenesin is an expectorant, and dextromethorphan is a centrally acting antitussive.