A 75-year-old client with a long history of depression is currently on doxepin (Sinequan), 100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu. Which nursing diagnosis should the nurse assign highest priority?
A. Risk for ineffective thermoregulation R/T anhidrosis
B. Risk for constipation R/T excessive fluid loss
C. Risk for injury R/T orthostatic hypotension
D. Risk for infection R/T suppressed white blood cell count
ANS: C
A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a combination of diuretic medication and flu symptoms can also contribute to this problem, putting this client at risk for injury R/T orthostatic hypotension.
You might also like to view...
Who was the nurse theorist who was the first American-trained nurse credited with teaching how to provide care for people with mental illness? _______________________
Answer
Which cardiac arrhythmia is the nurse most likely to assess in a patient with an embolic stroke?
A) Sinus tachycardia B) Atrial fibrillation C) First degree heart block D) Ventricular tachycardia
What factors influence cervical dilation? (Choose all that apply.)
1. Strong uterine contractions 2. The force of the presenting fetal part against the cervix 3. The size of the female 4. The pressure applied by the amniotic sac 5. Scarring of the cervix
The family of a suicidal client is very supportive and requests more facts related to caring for their family member after discharge. Which information should the nurse provide?
A. Address only serious suicide threats to avoid the possibility of secondary gain. B. Promote trust by verbalizing a promise to keep suicide attempt information within the family. C. Offer a private environment to provide needed time alone at least once a day. D. Be available to actively listen, support, and accept feelings.