A nurse is caring for a client in the outpatient mental health clinic

exhibits

Click to highlight the findings that indicate the client is experiencing adverse effects of the medication. To deselect a finding, click on the finding again
Nurses' Notes
Today

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation

Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

difficulty sleeping

frequent headaches

feeling much better

less fatigue

Answer and Explanation

The Correct Answer is ["A","B"]

Client states "I’m feeling much better." They report less fatigue even though they have difficulty sleeping. Client reports they are not sad anymore but are experiencing more frequent headaches. Client continues to deny any suicidal ideation
Vital Signs
Today
BP 149/91 mm Hg

Heart rate 75min

Respiratory rate 18/min

Explanation:

Based on the provided information, the following findings indicate the client may be experiencing adverse effects of the medication (fluoxetine):

Increased headaches: The client reports experiencing more frequent headaches, which can be an adverse effect of fluoxetine.
Difficulty sleeping (hypersomnia): The client reports difficulty sleeping despite feeling less fatigued, which could be related to the medication's effect on sleep patterns.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. Canned black beans are a good source of fiber and protein, but they are not specifically recommended for hypertension.
B. Cheese is often high in saturated fat and sodium, which can contribute to hypertension and cardiovascular risk.
C. Correct. Fish, especially fatty fish like salmon, mackerel, and trout, are rich in omega-3 fatty acids, which have been associated with cardiovascular benefits, including reducing blood pressure.
D. Red meat is often high in saturated fat and is not typically recommended for individuals with hypertension.

A. Allergic. B. Febrile nonhemolytic. C. Acute hemolytic. D. Bacterial.

Correct Answer is C

Explanation

Choice A rationale:

Allergic transfusion reactions are characterized by symptoms such as hives, itching, and shortness of breath. While allergic reactions can cause discomfort, they do not typically present with the symptoms described in the scenario, such as chills, headache, low-back pain, and chest tightness.

Choice B rationale:

Febrile nonhemolytic transfusion reactions are characterized by fever and chills, but they do not usually cause headache, low-back pain, or chest tightness. These reactions occur due to antibodies against donor leukocytes or platelets.

Choice C rationale:

Acute hemolytic transfusion reactions occur when there is a mismatch in blood type between the donor and recipient, leading to rapid destruction of transfused red blood cells. This reaction can cause symptoms such as chills, fever, low-back pain, chest tightness, and hemoglobinuria (presence of hemoglobin in the urine) It is a medical emergency that requires immediate cessation of the transfusion, supportive care, and treatment for potential complications such as acute kidney injury.

Choice D rationale:

Bacterial transfusion reactions occur due to bacterial contamination of the blood product. These reactions can cause symptoms such as fever, chills, hypotension, and shock. While bacterial transfusion reactions can be serious, the symptoms described in the scenario, including headache and low-back pain, are not typically associated with this type of reaction.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?

Correct Answer is C

Explanation

A nurse is monitoring a client who is receiving a transfusion of packed RBCs.The client reports chills, headache, low-back pain, and a feeling of "tightness" in his chest.The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is C

Explanation

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