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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":"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.


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Related Questions

Correct Answer is B

Explanation

Rationale:

A. Check the label of the medication twice prior to administration: Safe medication practice requires the nurse to check the medication label three times, when retrieving, preparing, and before administering to minimize the risk of medication errors.

B. Use two identifiers to verify the client's identity: Using two patient identifiers, such as name and date of birth, ensures the medication is given to the correct individual. This step is crucial for patient safety and is a core component of safe medication administration practices.

C. Document administration of the client's routine medications at the beginning of the shift: Medications should only be documented after they have been administered. Pre-charting medication administration can lead to errors if the medication is delayed, omitted, or refused.

D. Ensure the medication is administered within 3 hr of the scheduled time: Medications are typically required to be administered within 30 minutes to 1 hour of the scheduled time unless otherwise specified. A 3-hour window is too broad and may compromise therapeutic effectiveness.

Correct Answer is C

Explanation

Rationale:

A. Select a vein on the back of the hand: Veins on the dorsum of the hand are often more fragile and prone to infiltration or rupture in older adults. Using a more proximal site, such as the forearm, is generally safer and more stable for IV therapy.

B. Clean the site using vigorous friction: Older adults often have thinner, more delicate skin that can tear easily. While proper antiseptic technique is important, vigorous friction can cause skin trauma and should be avoided during site preparation.

C. Use a 22-gauge catheter for insertion: A 22-gauge catheter is appropriate for older adults because it minimizes vein trauma while still allowing for adequate flow rates. This size is effective for most fluids and medications while reducing the risk of vessel damage.

D. Apply a tourniquet firmly above the insertion site: Applying a tourniquet too tightly can injure fragile veins or cause them to collapse. In older adults, using minimal pressure or alternative vein-dilation methods like warm compresses is often safer.

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