A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations.
What is the priority action?
Ask if the patient has started any new prescription or over-the-counter medications.
Administer an anti-anxiety medication to subdue and sedate the patient.
Place the patient in loose bilateral arm restraints.
Tell the patient that the voices they are hearing are not real.
The Correct Answer is A
This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.
Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.
Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.
Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
To explain why, we need to use the formula for calculating the drip rate in drops per minute (dpm):
Volume of IV fluid (mL) x Drop Factor (drops/mL) / Time to run (h) x 60 (min/h) = Drip Rate (dpm)
In this question, the volume of IV fluid is one liter, which is equivalent to 1000 mL. The drop factor is 15 drops per mL, as given by the tubing.
The time to run is six hours, as ordered by the physician. Plugging these values into the formula, we get:
1000 mL x 15 drops/mL / 6 h x 60 min/h = 84 dpm
Therefore, the nurse should regulate the infusion to deliver 84 drops per minute.
Choice A is wrong because it gives a drip rate of 42 drops per minute, which is half of the correct answer.
This would result in delivering only 500 mL of normal saline in six hours, instead of one liter.
Choice C is wrong because it gives a drip rate of 100 drops per minute, which is more than the correct answer.
This would result in delivering 1.43 liters of normal saline in six hours, instead of one liter.
Choice D is wrong because it gives a drip rate of 166 drops per minute, which is almost double the correct answer.
This would result in delivering 1.99 liters of normal saline in six hours, instead of one liter.
Normal saline is a solution of 0.9% sodium chloride in water, which has the same osmolarity as blood plasma.
It is used to treat dehydration, shock, blood loss, and other conditions that require fluid replacement.
The normal range of sodium in blood is 135-145 mEq/L.
Correct Answer is A
Explanation
A client who grimaces during a dressing change is showing a nonverbal sign of pain. Grimacing is an expression of facial muscles that indicates discomfort or distress.
The nurse should record this as a symptom of pain and ask the client to rate the pain using a numeric or visual scale.
Choice B is wrong because an elevated heart rate while exercising is not necessarily a symptom of pain. It could be a normal response to increased physical activity or a sign of other conditions such as anxiety, dehydration, or fever.
Choice C is wrong because crying during a procedure is not a reliable indicator of pain. Crying is an emotional response that can be influenced by many factors such as fear, stress, or sadness.
The nurse should not assume that the client is in pain based on crying alone and should ask the client about the reason for crying and the level of pain.
Choice D is wrong because saying “I feel achy all over” is not a specific description of pain.
Aching is a vague term that can refer to different sensations such as soreness, stiffness, or cramping.
The nurse should ask the client to clarify what kind of pain they are feeling, where it is located, how severe it is, and what makes it better or worse.
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