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 C
Explanation
Rationale:
A. Temperature 36.8° C (98° F): This temperature is within the normal range and does not suggest a current or impending infection. It indicates stable thermoregulation in the postoperative period.
B. White blood cell count 8,000/mm³ (5,000 to 10,000/mm³): This WBC count falls within the normal reference range and does not reflect infection or inflammation. No abnormal immune response is indicated by this result.
C. Body mass index of 32: A BMI over 30 is classified as obesity, which increases the risk of poor wound healing and surgical site infections. Excess adipose tissue can impair circulation, oxygenation, and immune response at the wound site.
D. Blood glucose 90 mg/dL (74 to 106 mg/dL): This is a normal fasting glucose level and does not contribute to infection risk. Well-controlled glucose levels are favorable for wound healing and immune function.
Correct Answer is D
Explanation
Rationale:
A. Call in additional medical-surgical unit nursing care staff: The initial priority during a mass casualty event is to maximize available resources and free up beds by discharging stable clients. Staffing adjustments come after determining how to expand capacity.
B. Act as a liaison between the facility and the media: This role falls under the responsibilities of public relations or designated administrative personnel. Nurses should focus on patient care and operational tasks relevant to their scope during a crisis.
C. Determine the medical needs of incoming clients through the emergency department: Triage of incoming casualties is performed by designated emergency department staff. Nurses from other units typically assist by creating space or relocating stable clients.
D. Recommend to the provider specific acute care clients for discharge: Identifying stable clients who can be safely discharged allows beds and resources to be allocated to incoming critical cases. This is an appropriate and immediate nursing response during mass casualty.
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