A nurse is assisting with the care of a client
Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
The client is at risk for developing
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Rationale for correct choices:
• Serotonin syndrome: The client presents with restlessness, abdominal pain, disorientation, and fever shortly after an increase in paroxetine, a selective serotonin reuptake inhibitor (SSRI). These symptoms are consistent with serotonin toxicity, which can develop when serotonergic medications are started or doses increased. Early recognition is critical because serotonin syndrome can progress rapidly and become life-threatening without prompt intervention.
• Adverse effects of paroxetine: The recent increase in paroxetine dosage to 30 mg daily places the client at risk for serotonergic adverse effects. Symptoms such as restlessness, gastrointestinal upset, and mental status changes reflect this risk. Identifying medication-related adverse effects allows the nurse to alert the provider for evaluation and potential dose adjustment or discontinuation.
Rationale for incorrect choices:
• Agoraphobia: The client does not exhibit fear of public spaces or avoidance behaviors typical of agoraphobia. Current symptoms are acute and physiological rather than anxiety-driven avoidance. Therefore, this condition does not explain the presenting findings.
• Bulimia: The client does not report binge eating, purging, or restrictive behaviors. Gastrointestinal symptoms are linked to medication effects rather than eating disorder behaviors. Bulimia is inconsistent with the acute presentation and current assessment.
• Mania: Manic symptoms include elevated mood, hyperactivity, decreased need for sleep, and impulsivity. The client reports hopelessness, disinterest, and lethargy rather than hyperactive or expansive mood changes. Mania is therefore unlikely. The presentation aligns more with serotonergic toxicity.
• Hypertensive crisis: Hypertensive crisis typically presents with severe headache, elevated blood pressure, visual changes, and possible neurological deficits. The client’s blood pressure is not noted as elevated, and symptoms focus on gastrointestinal and neurological changes. Medication risk for hypertensive crisis is more relevant with MAO inhibitors, not SSRIs.
• Abdominal pain: While the client reports abdominal discomfort, it is a symptom rather than a cause of risk. Abdominal pain is a manifestation of serotonin syndrome rather than an independent risk factor. It does not identify the underlying condition requiring immediate intervention.
• Recent fall: Although a recent fall is noted, it did not result in head trauma and is unlikely related to the acute presentation. The fall is not causative for serotonin syndrome. It may warrant monitoring but does not explain current physiological changes.
• Anxiety: The client has a history of generalized anxiety disorder, but current acute symptoms (fever, disorientation, restlessness) exceed baseline anxiety levels. Anxiety alone does not account for fever or neurologic changes. The acute presentation is medication-related rather than purely psychiatric.
• Feelings of hopelessness: Hopelessness is part of the client’s underlying depressive disorder, not the acute risk factor. While it may impact overall mental health, it does not directly cause serotonin syndrome. Monitoring mood is important but secondary to physiological assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. Respiratory rate: A respiratory rate of 30 breaths per minute indicates significant respiratory distress. Labored breathing combined with crackles and wheezes suggests impaired gas exchange and possible lower respiratory infection requiring urgent intervention.
B. Oxygen saturation level: An oxygen saturation of 89% on room air reflects hypoxemia. Reduced oxygen levels place the client at risk for tissue hypoxia and worsening respiratory failure, making prompt follow-up and oxygen therapy necessary.
C. Chronic health condition: A history of smoking, Parkinson’s disease, and anxiety increases overall health risk but does not explain the acute deterioration. Chronic conditions provide context but are not the immediate priority compared with current unstable findings.
D. Tremors: Hand tremors are consistent with Parkinson’s disease and may also be worsened by anxiety or illness. Tremors alone do not pose an immediate life-threatening risk in this situation.
E. Current level of consciousness: Orientation only to self and failure to follow commands suggest acute changes in mental status. Altered cognition in an older adult with fever and hypoxia may indicate delirium or worsening infection and requires immediate evaluation.
F. Heart rate: A heart rate of 104 beats per minute indicates mild tachycardia, likely related to fever or hypoxia. Although important to monitor, it is less immediately threatening than hypoxemia, tachypnea, and altered mental status.
Correct Answer is A
Explanation
A. Raises all four side rails on the client's bed: Raising all four side rails can create a restraint situation, increasing the risk of entrapment or injury. Current safety guidelines recommend using only two side rails and employing other fall-prevention strategies instead.
B. Locks the wheels on the client's bed: This is a standard safety measure. Locking the wheels ensures the bed does not move when the client attempts to sit up or get out of bed, reducing fall risk. This is an appropriate safety measure for clients at risk for falls.
C. Assists the client to the bathroom every 2 hr: Regularly assisting the client to the bathroom reduces the likelihood of unassisted ambulation, which can prevent falls. Scheduled toileting is a recommended intervention for fall prevention.
D. Clears furniture from the path leading to the bathroom: Removing obstacles ensures a clear walking path and minimizes tripping hazards. Removing environmental hazards, such as clutter, loose rugs, or excess furniture, creates a clear, safe pathway for the client and reduces the risk of tripping.
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