A nurse is caring for a client at a clinic.
Complete the following sentence by using the lists of options.
The client is at risk for developing
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Rationale:
A. Bradypnea: Clients with end-stage kidney disease are more likely to experience Kussmaul respirations (rapid, deep breathing) as the body attempts to compensate for metabolic acidosis by exhaling excess carbon dioxide. Bradypnea is not a typical finding in renal failure and would indicate a different respiratory issue.
B. Oliguria: As kidney function declines, urine output decreases because the kidneys lose their ability to filter and excrete waste products effectively. Oliguria, or markedly reduced urine output, is a hallmark of end-stage renal disease and contributes to fluid overload.
C. Anemia: The kidneys normally produce erythropoietin, which stimulates red blood cell production. In end-stage kidney disease, decreased erythropoietin production leads to anemia, resulting in fatigue, pallor, and decreased oxygen-carrying capacity.
D. Hypotension: Clients with kidney failure often experience hypertension rather than hypotension due to fluid retention and activation of the renin-angiotensin-aldosterone system. Hypotension would be more characteristic of acute volume depletion, not chronic renal failure.
E. Edema: Impaired kidney function causes sodium and water retention, leading to fluid accumulation in tissues. Peripheral and periorbital edema are common manifestations of end-stage kidney disease due to reduced excretion of excess fluid.
Correct Answer is A
Explanation
Rationale:
A. Limited hip abduction: Restricted hip movement in an infant can indicate developmental dysplasia of the hip (DDH). Early detection is essential because delayed treatment may lead to permanent hip deformities, gait abnormalities, and the need for surgical intervention.
B. Symmetric gluteal and thigh skin folds: Symmetry of gluteal and thigh folds is a normal finding in infants. Asymmetry may be a sign of DDH, but symmetric folds generally indicate normal hip development and do not require referral.
C. Equal leg length: Equal length of both legs is a normal musculoskeletal finding. Leg length discrepancy can be associated with hip dislocation or dysplasia, but equal lengths suggest proper femoral positioning.
D. Femoral head remains in the acetabulum during the Barlow maneuver: A stable femoral head during the Barlow test indicates normal hip stability. If the femoral head dislocates or is reducible, referral for orthopedic evaluation would be warranted.
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