A nurse is assisting with the care for a newly admitted client who has major depressive disorder.

Exhibits

Select 1 condition and 1 client finding to fill in each blank in the following sentence (Separate using a comma).

The client is at risk for developing
dropdown
due to the Client's intake of
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

The client is at risk for developing Serotonin syndrome due to the Client's intake of St. John's wort

Explanation:

St. John's wort is an herbal supplement that can interact with certain medications, including selective serotonin reuptake inhibitors (SSRIs) and other medications that increase serotonin levels. Serotonin syndrome is a potentially life-threatening condition characterized by an excess of serotonin in the body.

In the given scenario, the nurse should identify:

Condition: The client's intake of St. John's wort

Client Finding: At risk for developing serotonin syndrome

This is because the use of St. John's wort, combined with medications that affect serotonin levels, increases the risk of serotonin syndrome. The nurse should monitor for symptoms of serotonin syndrome, such as changes in vital signs, hyperthermia, altered mental status, and neuromuscular abnormalities. If serotonin syndrome is suspected, medical attention should be sought promptly.

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Correct Answer is B

Explanation

A. Constantly talking about the traumatic experience is a symptom of intrusive thoughts and re-experiencing, which is characteristic of PTSD.

B. The client is easily startled by loud voices.
Individuals with PTSD often experience heightened arousal and increased reactivity to stimuli. Being easily startled by loud voices is a common symptom of hypervigilance and increased arousal seen in PTSD.

C. Reporting satisfying personal relationships with family and close friends is less likely in individuals with PTSD. PTSD can negatively impact interpersonal relationships due to symptoms such as emotional numbing, avoidance, and hypervigilance.

D. Constant drowsiness and sleeping 11-12 hours daily are not typical findings in PTSD. Individuals with PTSD may experience sleep disturbances, such as insomnia, nightmares, or hyperarousal-related sleep problems.

A. Loss of appetite B. vomiting and diarrhea C. increased flatulence D. Increased urination

Correct Answer is B

Explanation

A. Loss of appetite is not a specific manifestation of lithium toxicity. However, gastrointestinal symptoms like nausea and vomiting can contribute to a decreased appetite.

B. Vomiting and diarrhea.
Lithium is a mood stabilizer commonly used in the treatment of bipolar disorder. Toxicity can occur, and symptoms can range from mild to severe. Vomiting and diarrhea are common early signs of lithium toxicity. As toxicity progresses, it can lead to more severe symptoms, such as tremors, confusion, and potentially life-threatening complications.

C. Increased flatulence is not a typical manifestation of lithium toxicity. Gastrointestinal symptoms associated with lithium toxicity are more likely to include nausea, vomiting, and diarrhea.

D. Increased urination is not a typical manifestation of lithium toxicity. Lithium can affect renal function, leading to decreased urine output, but it does not typically cause increased urination as a sign of toxicity.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who witnessed her brother's homicide and has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client about manifestations of lithium toxicity. Which of the following manifestations should the nurse include in the teaching?

Correct Answer is B

Explanation

A nurse is collecting data from a client admitted to an inpatient mental health unit and has a new prescription for disulfiram (Antabuse). Which of the following information is most important for the nurse to obtain before administering this medication?

A nurse is caring for a client who has obsessive compulsive disorder (OCD) and is constantly picking up after others and cleaning in the day room. The nurse should recognize the client's actions as which of the following?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, "I'm frightened. Do you hear that? The voices are telling me to do terrible things." Which of the following responses by the nurse is appropriate?

A nurse is collecting data from a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?

A nurse is assisting with the plan of care for a client who is newly diagnosed with borderline personality disorder. Which of the following Interventions is the nurse's priority?

As part of the plan of care for a client with borderline personality disorder, the nurse reviews the day's schedule with him each morning. While doing so, the client states. "Why don't you shut up already! I can read it myself, you know!" Which of the following is an appropriate nursing response?

A nurse is caring for a client who has schizophrenia. Exhibits Select the "3" findings that should indicate to the nurse the client is experiencing negative symptoms related to their schizophrenia.