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":"B","dropdown-group-2":"A"}
Rationale for Correct Choices:
- Serotonin syndrome: The client presents with restlessness, fever, abdominal pain, and disorientation all classic signs of serotonin syndrome. These symptoms developed after a recent dose increase of a serotonergic medication, indicating a likely adverse drug reaction.
- Adverse effects of paroxetine: Paroxetine, an SSRI, can cause serotonin syndrome, especially when recently increased or combined with other serotonergic agents. The timing of the dose escalation aligns with the emergence of the client’s acute symptoms.
Rationale for Incorrect Choices:
- Psychosis: While disorientation is present, there is no evidence of hallucinations, delusions, or loss of reality testing, which are essential features of psychosis.
- Mania: The client does not show signs of elevated mood, grandiosity, pressured speech, or risky behavior, which are typical of mania.
- Anxiety: Although anxiety is part of the client’s history, the sudden onset of fever and autonomic instability points more clearly to a toxic reaction rather than worsening anxiety.
- Fluoxetine discontinuation: Fluoxetine has a long half-life, and discontinuation typically causes delayed withdrawal symptoms like dizziness or mood swings not the acute systemic symptoms noted here.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Pale and a 24-hr fluid deficit of 30 mL: Mild pallor and a small fluid deficit are not uncommon in early stages of illness and may not require immediate intervention. However, more serious signs of dehydration would take priority for reporting.
B. Temperature 38° C (100.4° F) and pulse rate 124/min: These are within expected limits for an infant with mild infection or fever. While they should be monitored, they are not urgent indicators of severe complications from gastroenteritis.
C. Decreased appetite and irritability: These are common symptoms in infants with viral illnesses, including gastroenteritis. Although they affect comfort and feeding, they are not necessarily indicators of serious fluid or electrolyte imbalance.
D. Sunken fontanels and dry mucous membranes: These are clinical signs of moderate to severe dehydration, which is a serious complication of gastroenteritis in infants. These findings must be reported promptly for urgent intervention to prevent further deterioration.
Correct Answer is A
Explanation
Rationale:
A. Establish a patent oral airway: The airway is the highest priority in trauma care, following the ABCs (Airway, Breathing, Circulation). Without a patent airway, the client cannot oxygenate properly, which can quickly become life-threatening.
B. Remove the client's clothing: This helps with full-body assessment and prevention of missed injuries, but it should only be done after ensuring the client’s airway and breathing are stable.
C. Warm blood products prior to administration: While this helps prevent hypothermia during transfusion, warming blood is not the immediate priority in a trauma situation. Circulation support follows airway and breathing in priority.
D. Assign the client a score on the Glasgow Coma Scale: Neurological assessment is important but comes after airway stabilization. The GCS helps evaluate consciousness but should not delay securing the airway in an emergency.
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