A nurse is assisting in the care of a client.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
Check deep tendon reflexes.
Discontinue fluoxetine.
Administer citalopram.
Administer phenelzine.
Administer propranolol.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}
- Check deep tendon reflexes: The client exhibits restlessness, diaphoresis, tachycardia, elevated temperature, and gastrointestinal symptoms, which are consistent with serotonin syndrome. Hyperreflexia and clonus are key neuromuscular findings associated with this condition. Assessing deep tendon reflexes helps confirm neuromuscular hyperactivity.
- Discontinue fluoxetine: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels and can precipitate serotonin syndrome. The client’s symptoms developed after initiating this medication, suggesting toxicity. Immediate discontinuation removes the source of excess serotonin.
- Administer citalopram: Citalopram is another SSRI that increases serotonin activity. Administering it while the client is experiencing serotonin toxicity would worsen the condition. Adding another serotonergic agent could intensify hyperthermia, autonomic instability, and neuromuscular symptoms.
- Administer phenelzine: Phenelzine is a monoamine oxidase inhibitor (MAOI) that significantly increases serotonin levels. Combining or switching to an MAOI in the setting of suspected serotonin syndrome is dangerous and can precipitate severe toxicity. MAOIs require a washout period after SSRIs due to fluoxetine’s long half-life.
- Administer propranolol: Propranolol may be used to manage autonomic instability such as tachycardia and hypertension associated with serotonin syndrome. The client’s elevated heart rate and blood pressure support this intervention. Controlling sympathetic overactivity reduces cardiovascular strain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Instruct the client to report the theft to the police: While reporting to law enforcement is an option, the client may feel intimidated or unsafe doing so, and immediate protection and assessment of the situation are more urgent. The nurse’s priority is ensuring safety and initiating appropriate protective services.
B. Report the possible abuse to adult protective services: Financial exploitation is a form of elder abuse. Nurses are mandated reporters and should notify adult protective services to investigate and intervene as needed. This ensures the client’s safety, prevents further exploitation, and connects them with resources for protection and support.
C. Ask the client if there is another family member they can call for financial help: While exploring support systems is important, relying on another family member without assessment may not address potential abuse and does not fulfill the nurse’s legal obligation to report suspected exploitation.
D. Restrict visitation for the client's family until discharge: Restricting visitation may limit contact temporarily, but it does not address the underlying abuse or ensure ongoing protection. Reporting to protective services provides a structured and legal mechanism for safeguarding the client.
Correct Answer is B
Explanation
A. Tell the children to alternate standing on one foot and observe their balance: Assessing balance does not evaluate spinal curvature or detect scoliosis. While balance testing may identify neuromuscular issues, it is not part of standard scoliosis screening and does not reveal lateral spinal deviations.
B. Ask the children to bend forward at the waist and observe them from behind: The forward bend (Adam’s forward bend) test is the recommended screening method for scoliosis. Observing from behind allows the nurse to detect asymmetry in the shoulders, ribs, or hips, which may indicate spinal curvature. This method is simple, noninvasive, and effective for early detection.
C. Tell the children to stand up straight and observe them facing forward: Viewing the child from the front while standing upright may reveal gross asymmetry but is less sensitive than the forward bend test. Subtle spinal curvatures are often not noticeable when the child is standing upright.
D. Ask the children to raise their hands over their head and turn from side to side: Raising arms and twisting does not provide clear visualization of spinal asymmetry. Scoliosis screening relies on observing the alignment of the spine and rib cage during forward flexion, not rotational movements.
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