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
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due to the Client's intake of
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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. 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.

A. Identification B. Relation-formation C. Projection D. Compensation

Correct Answer is C

Explanation

A. Identification: Identification involves taking on the characteristics of another person, group, or entity. The client's response is not an example of identification.

B. Relation-formation: This term is not a recognized defense mechanism in the context of classical psychoanalytic theory. It seems to be a combination of two concepts but doesn't fit the context of the client's statement.

C. Projection
Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or impulses to another person. In this scenario, the client is projecting their own feelings of anger and a desire to have a drink onto the nurse and others, suggesting that the staff is angry at them and wants to go out for a drink.

D. Compensation: Compensation involves making up for a perceived weakness by emphasizing a strength in another area. The client's statement do

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Naxlex Comprehensive Predictor Exams

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 assisting with the court-ordered admission of a client to a substance-abuse program. The client states, "You are all angry at me and wish you could go out and have a drink." The client's response is an example of which of the following defense mechanisms?

Correct Answer is C

Explanation

A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?

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?

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

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A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse's priority?

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A nurse in an acute care mental health facility is contributing to the plan of care for a client who is newly diagnosed with schizophrenia and is verbalizing paranoid delusions. Which of the following interventions should the nurse include in the plan?