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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Nitrites negative: Nitrites in the urine are typically produced by certain gram-negative bacteria that convert nitrates to nitrites. A negative nitrite result suggests the absence of common bacterial urinary tract infection pathogens and is considered a normal finding.

B. Ketones positive: Positive urinary ketones indicate fat breakdown and possible metabolic imbalance. In adolescents, this may be associated with uncontrolled diabetes mellitus, prolonged fasting, eating disorders, or dehydration. The presence of ketones raises concern for diabetic ketoacidosis if accompanied by hyperglycemia, making provider notification necessary.

C. Uric acid 475 mg/24 hr: Normal 24-hour urinary uric acid excretion typically ranges from approximately 250 to 750 mg. A value of 475 mg/24 hr falls within expected limits and does not indicate metabolic or renal dysfunction requiring intervention.

D. Specific gravity 1.020: Normal urine specific gravity ranges from about 1.005 to 1.030, reflecting appropriate renal concentrating ability. A value of 1.020 indicates adequate hydration and kidney function, and it does not suggest pathology requiring provider notification.

A. Ecchymosis in the exposed portion of the left foot B. Inability to move the left foot C. Paresthesia in the left foot D. Pallor in the exposed portion of the left foot E. Increased warmth of the exposed portion of the left foot

Correct Answer is ["B","C","D"]

Explanation

A. Ecchymosis in the exposed portion of the left foot: Bruising may occur with the initial injury or minor trauma but is not a reliable early indicator of compartment syndrome. Ecchymosis does not reflect the elevated pressure within the fascial compartment that compromises circulation and nerve function.

B. Inability to move the left foot: Motor deficits, such as inability to move the toes or foot, indicate nerve compression and ischemia within the compartment. This is a late but critical sign of compartment syndrome, requiring immediate evaluation to prevent permanent damage.

C. Paresthesia in the left foot: Tingling, numbness, or “pins and needles” sensation is an early sign of nerve ischemia caused by increased compartment pressure. Paresthesia often precedes motor deficits and is an important symptom for early recognition and intervention.

D. Pallor in the exposed portion of the left foot: Pale skin indicates compromised arterial blood flow resulting from elevated intracompartmental pressure. Pallor reflects ischemia and is a classic clinical sign of compartment syndrome requiring urgent intervention.

E. Increased warmth of the exposed portion of the left foot: Compartment syndrome usually causes decreased perfusion, leading to cool or cold extremities rather than warmth. Increased warmth is more commonly associated with infection or inflammation, not compartment syndrome.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a pediatric clinic is reviewing the urine laboratory results for an adolescent. For which of the following results should the nurse notify the provider?

Correct Answer is B

Explanation

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identity as an indication that the client might have compartment syndrome? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

A nurse is reinforcing teaching about the purpose of quadruple screening for a client who is at 16 weeks of gestation. Which of the following statements should the nurse make?

A nurse is caring for several clients who are receiving well-child check-ups. The nurse should identify that the initial diphtheria, tetanus, and pertussis (DTaP) vaccine is indicated for which of the following clients?

A nurse from a medical-surgical unit is floating to a postpartum unit. Which of the following clients is an appropriate assignment for the nurse to accept?

A charge nurse in a long-term care unit is planning care for a group of clients. Which of the following care tasks should the nurse plan to delegate to an assistive personnel?

A nurse is establishing a baseline postoperative assessment for a client who is recovering from a right femoropopliteal bypass graft. Which of the following findings in the assessment of the client's right leg should be of the most concern to the nurse?

A nurse is collecting data from a client who has pneumonia and reports shortness of breath. The nurse notes the client has crackles auscultated in the lower lobes and an SaO2 of 88% on room air. Which of the following actions should the nurse take first?

A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem-solving skills?

A hospice nurse is caring for a client who has a terminal illness. Which of the following client statements should the nurse identify as an indication that the client is experiencing the bargaining stage of grief?

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.