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A nurse is caring for a client at a clinic.

Exhibits

Complete the following sentence by using the lists of options.

The client is at risk for developing

due to .
Answer and Explanation

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

Rationale for Correct Choices:

• Serotonin syndrome: The client’s symptoms recent SSRI dose increase indicate possible serotonin toxicity. Serotonin syndrome occurs when excessive serotonin accumulates in the body, typically following dose escalation or interaction between serotonergic medications. It is a medical emergency that can progress to seizures or death if not promptly identified and treated.

• Adverse effects of paroxetine: The increase in paroxetine dosage one week prior likely triggered excessive serotonergic activity. Paroxetine, an SSRI, elevates serotonin levels, and dose escalation can precipitate serotonin syndrome.

Rationale for Incorrect Choices:

• Generalized anxiety disorder: Although the client has a history of anxiety, the acute onset of fever, disorientation, and autonomic instability points to a physiological reaction rather than worsening anxiety. Anxiety may cause restlessness but does not produce hyperthermia or confusion.

• Neuroleptic malignant syndrome: This condition is associated with antipsychotic drugs, not SSRIs like paroxetine. While both syndromes can present with fever and altered mental status, the client’s medication profile and timing support serotonin toxicity instead.

• Feelings of hopelessness: Although ongoing hopelessness is part of the client’s depression, it does not explain the acute physical manifestations. Emotional symptoms may persist with depression, but fever and disorientation indicate a pharmacologic rather than psychological cause.

• Anxiety: Anxiety alone cannot account for the client’s fever, disorientation, or abdominal pain. These findings suggest a systemic reaction consistent with serotonin excess, not a purely psychological state.


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Related Questions

Correct Answer is C

Explanation

Rationale:
A. "This medication can increase your risk for osteoporosis.": Long-term warfarin use may affect bone density slightly, but this is not the primary teaching point for safety and daily management. It is less immediately relevant than bleeding risk.

B. "This medication can cause hearing loss.": Warfarin is not associated with ototoxicity or hearing loss; this statement does not reflect a known adverse effect of the medication.

C. "Avoid drinking cranberry juice while taking this medication.": Cranberry products can interact with warfarin and increase the risk of bleeding by potentiating its anticoagulant effect. Clients should be advised to avoid or limit cranberry intake to maintain safe INR levels.

D. "Increase your intake of foods high in vitamin K while taking this medication.": Consuming consistent amounts of vitamin K is important, but the client does not need to increase intake. Sudden increases can counteract warfarin’s effect; the emphasis is on maintaining a stable vitamin K intake.

Correct Answer is D

Explanation

Rationale:
A. Hold the sterile package in his dominant hand and open the top flap of the package toward his body: The top flap should be opened away from the nurse’s body to avoid reaching over and contaminating the sterile field. Opening toward the body risks touching or dropping contaminants onto the field.

B. Drop the sterile gauze from 25.4 cm (10 in) above the sterile field: Sterile items should be dropped from a minimal height, close to the field, to prevent them from bouncing, falling off, or becoming contaminated. A 10-inch drop increases the risk of contamination.

C. Place objects 1.27 cm (0.5 in) inside the border of the sterile field: The outer 1 inch (2.5 cm) of a sterile field is considered contaminated, not just 0.5 inches. Placing objects inside only 0.5 in does not guarantee sterility and may result in contamination.

D. Position the bottle outside the edge of the sterile field when pouring solution into a sterile container: Keeping the bottle outside the sterile field prevents contamination from the outside of the bottle. Only the sterile contents should enter the sterile container, maintaining the integrity of the sterile field during the dressing change.

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