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 A
Explanation
Rationale:
A. Use a powered lift to transfer the client: When a client is unable to assist and weighs significantly over standard lifting limits, a powered mechanical lift is the safest and most appropriate method. It reduces the risk of musculoskeletal injury to staff and ensures safe, controlled client movement.
B. Wrap their arms under the client's axilla to transfer the client: This manual lifting method can cause harm to both the nurse and the client. It increases the risk of shoulder injury for the client and back strain for the nurse, especially when the client is immobile and heavy.
C. Use a gait belt to transfer the client: Gait belts are used for clients who can bear some weight and assist in the transfer. Since this client cannot assist, a gait belt is insufficient and may result in injury or unsafe movement.
D. Use a sliding board to transfer the client: Sliding boards are typically used when clients have upper body strength and can assist in shifting their weight. For a fully dependent client of this size, it is not a safe or effective method without mechanical assistance.
Correct Answer is A
Explanation
Rationale:
A. “You can obtain a personal response system that will be activated if you fall.": Personal emergency response systems (PERS) allow individuals who live alone to call for help immediately in case of a fall or emergency.
B. “You need to move to a skilled nursing facility where they can prevent falls.": Moving to a skilled nursing facility is a major step and is not necessary solely due to fear of falling. It may also provoke anxiety or feelings of loss of autonomy, especially if less invasive alternatives are available.
C. "You can have an unlicensed assistive personnel (UAP) come to your house daily to stay with you.": Daily UAP support may not be realistic or necessary for someone who is still generally independent. This level of care may be excessive unless the client has significant mobility or cognitive impairments.
D. "You should contact a family member once a week to keep in touch.": While weekly contact with family can offer emotional support, it does not provide real-time assistance in the event of a fall. It’s not a sufficient solution for immediate safety concerns.
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