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Difficulty: EasyPharmacological and Parenteral Therapies

An ambulatory client who recently started taking oral lisinopril for hypertension contacts the clinic to report several new symptoms. Which of the following client reports requires the most immediate intervention by the nurse?

  1. My lips and tongue feel unusually thick and swollen.Answer
  2. B
    I have developed a persistent, dry cough that is quite annoying.
  3. C
    I feel mildly lightheaded when I stand up too quickly in the morning.
  4. D
    I have noticed a slight metallic taste in my mouth when I eat.

Answer

The client reporting thick and swollen lips and tongue requires the most immediate intervention.
The report of swollen lips and tongue strongly suggests angioedema, a rare but highly dangerous adverse effect of ACE inhibitors like lisinopril. Angioedema involves rapid swelling of the deep dermis and subcutaneous tissues around the face, mouth, and throat, which can quickly occlude the airway. Using the ABC (Airway, Breathing, Circulation) prioritization framework, securing and protecting a compromised airway is always the highest clinical priority.

Step-by-Step Solution

1
Analyze the client's medication and identified symptoms.
The client is taking lisinopril (an ACE inhibitor) and reports swelling, cough, dizziness, and altered taste.
Identifying the medication's adverse effect profile is necessary to differentiate between expected side effects and severe hypersensitivity reactions.
2
Prioritize the symptoms using the ABCs (Airway, Breathing, Circulation) framework.
Swelling of the lips and tongue (angioedema) threatens the Airway, making it the absolute highest priority.
Airway compromise is an immediate, life-threatening emergency that always takes precedence over chronic or systemic findings.

Key Concept

ACE Inhibitor Adverse Effects and Airway Prioritization
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Topics

Pharmacological and Parenteral Therapies

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