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 []
Explanation
Rationale for Correct Choices
• Heart failure: The client has classic signs of heart failure, including S3 heart sound, bilateral crackles, lower extremity edema, elevated BNP, and cool extremities, indicating fluid overload and decreased cardiac output. Early identification allows timely interventions to prevent decompensation.
• Obtain a prescription for a diuretic: Diuretics reduce fluid retention, alleviate pulmonary congestion, and improve oxygenation. Administering a diuretic helps manage the client’s edema, dyspnea, and fatigue, reducing cardiac workload.
• Educate the client about sodium restriction : Limiting dietary sodium prevents further fluid retention and helps control blood pressure, reducing the risk of exacerbating heart failure symptoms and hospital readmission.
• Blood pressure: Monitoring BP is essential in heart failure to detect hypotension from decreased cardiac output or over-diuresis. Maintaining safe BP ensures adequate perfusion and guides treatment adjustments.
• Daily weight: Daily weights are a sensitive measure of fluid status. Rapid increases indicate fluid accumulation, allowing early interventions with diuretics or fluid management to prevent worsening heart failure.
Rationale for Incorrect Choices
• Aortic stenosis: Aortic stenosis primarily causes systolic murmur, angina, syncope, and sometimes heart failure over time. This client’s presentation is dominated by fluid overload and elevated BNP, with no auscultatory evidence of stenotic valve disease.
• Endocarditis : Endocarditis is associated with fever, positive blood cultures, heart murmurs, and skin lesions like Janeway lesions or Osler nodes. This client has no signs of infection, making endocarditis unlikely.
• Mitral stenosis : Mitral stenosis produces a diastolic murmur, pulmonary congestion, and sometimes atrial fibrillation. While some pulmonary signs may overlap with heart failure, this client lacks the characteristic murmur and risk factors for mitral stenosis.
• Prepare the client for cardioversion : Cardioversion is indicated for arrhythmias such as atrial fibrillation with rapid ventricular response. The client’s heart rhythm is regular, making this action unnecessary.
• Administer antibiotics as prescribed : Antibiotics are used for infections such as endocarditis or sepsis. This client has no fever, abnormal labs, or signs of systemic infection, so antibiotics are not indicated.
• Educate the client about valve replacement : Valve replacement education is relevant only if the client has significant valvular disease. This client’s data show no evidence of aortic or mitral valve pathology, so this action is not needed.
• Fever : Monitoring for fever is critical in infection or sepsis. Since the client’s temperature is normal, this is not an immediate concern.
• Blood cultures : Blood cultures identify bacteremia or endocarditis. The client has no infection indicators; therefore, this parameter is unnecessary.
• Skin lesions : Skin lesions such as Osler nodes or Janeway lesions indicate infective endocarditis. The client shows no such lesions, making monitoring irrelevant in this scenario.
Correct Answer is B
Explanation
Rationale:
A. Discourage the client from allowing friends to see the newborn: Restricting contact can hinder the grieving process. Allowing the client and close family or friends to see and hold the baby can help them acknowledge the loss, express emotions, and begin healthy mourning.
B. Offer to take pictures of the newborn for the client: Offering photographs provides the family with tangible memories that can support the grieving and healing process. Many parents later find comfort in having keepsakes, even if they initially decline them.
C. Assure the client that she can have additional children: Statements about future pregnancies minimize the client’s current grief and loss. The nurse should focus on supporting the client’s emotional needs in the present rather than redirecting attention.
D. Avoid talking to the client about the newborn: Avoiding discussion invalidates the client’s feelings and may intensify emotional isolation. Talking about the newborn by name, if known, acknowledges the baby’s existence and validates the parents’ grief, which is essential for emotional healing.
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