A client in an acute mental health facility is experiencing withdrawal from Opioid use and has a new prescription for Clonidine. Which of the following actions should the nurse identify as the priority?

Correct Answer: D

Rationale: In this scenario, the priority action for the nurse is to obtain baseline vital signs. This step is crucial in assessing the client's current physiological status and establishing a reference point for monitoring the effects of Clonidine. Administering the medication, providing ice chips, and educating the client are important tasks but assessing the client's vital signs takes precedence to ensure the client's safety and well-being during withdrawal management.

Correct Answer: C

Rationale: The correct answer is C because Warfarin interacts with vitamin K, found in green leafy vegetables, not potassium. The client should avoid consuming large amounts of foods high in vitamin K to maintain the effectiveness of Warfarin therapy. Increasing potassium intake is not a concern related to Warfarin therapy, so this statement indicates a need for further teaching.

Correct Answer: B

Rationale: Spironolactone is a potassium-sparing diuretic, meaning it can cause potassium retention, leading to elevated potassium levels. A potassium level of 5.2 mEq/L is above the normal range (3.5-5.0 mEq/L) and indicates hyperkalemia, which can be a serious condition. Therefore, this finding should be promptly reported to the healthcare provider for further evaluation and management to prevent potential complications.

Correct Answer: B

Rationale: In this scenario, the correct instruction that the healthcare professional should include is to "Increase intake of foods high in potassium" (Option B). Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes such as sodium and potassium from the body. Therefore, patients taking Furosemide are at risk of developing hypokalemia, a condition characterized by low potassium levels. Educationally, it is crucial to explain to patients the importance of maintaining adequate potassium levels to prevent adverse effects such as muscle weakness, irregular heartbeats, and fatigue. Encouraging the consumption of potassium-rich foods like bananas, oranges, potatoes, and spinach is essential to counteract the potassium loss caused by Furosemide. Regarding why the other options are incorrect: A) Taking the medication with breakfast (Option A) is not the priority instruction for a patient taking Furosemide. While timing of medication administration is important, it is not directly related to the potential side effects of Furosemide. C) Avoiding prolonged sun exposure (Option C) is not directly related to the use of Furosemide. Furosemide does not typically increase photosensitivity, so this instruction is not necessary in this context. D) Limiting sodium intake (Option D) is a general health recommendation but is not the most critical instruction for a patient specifically prescribed Furosemide. Furosemide already works to reduce sodium levels in the body, so the focus should be on potassium-rich foods instead.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) The client experiences a decrease in episodes of angina. Rationale: 1. **Correct Answer (C)**: Aspirin is commonly prescribed for cardiovascular disease prevention due to its antiplatelet effects. A decrease in episodes of angina indicates improved blood flow to the heart, suggesting that the medication is effectively preventing clot formation and reducing the risk of cardiovascular events. 2. **Incorrect Answer (A)**: A decrease in troponin levels would be indicative of reduced myocardial damage, potentially due to a heart attack. However, this is not a direct indicator of Aspirin's effectiveness in preventing cardiovascular disease. 3. **Incorrect Answer (B)**: While having a regular heart rhythm is important for cardiovascular health, it is not a specific indicator of Aspirin's effectiveness in preventing cardiovascular disease. 4. **Incorrect Answer (D)**: Stable blood pressure is important for overall health but does not directly reflect the effectiveness of Aspirin in preventing cardiovascular events. Educational Context: Understanding the rationale behind the effectiveness of medications used in cardiovascular disease prevention is crucial for healthcare professionals. Monitoring outcomes such as a decrease in anginal episodes helps assess the efficacy of treatment and guides further management decisions. This question highlights the importance of recognizing specific indicators of medication effectiveness in clinical practice.