A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider?

Sweating and fever

Discolored urine

Decreased appetite

Hallucinations.

Answer and Explanation

The Correct Answer is D

Choice A rationale: Sweating and fever are not typically associated with buspirone use. These symptoms could be indicative of another underlying condition or a different medication side effect.

Choice B rationale: Discolored urine is not a common side effect of buspirone. If a patient experiences this, it may be due to other factors such as dehydration, certain foods, or other medications.

Choice C rationale: Decreased appetite is not a common side effect of buspirone. While some medications can affect appetite, buspirone is not typically associated with significant changes in appetite.

Choice D rationale: Hallucinations are a serious side effect and should be reported to the provider immediately. Although rare, buspirone can cause severe side effects such as mental depression, confusion, and uncontrolled

movements of the body. If a patient experiences hallucinations while taking buspirone, it could indicate a serious adverse reaction that requires immediate medical attention.

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Correct Answer is D

Explanation

Administering the Hamilton Depression Scale is a tool used to assess the severity of depression. While it can provide valuable information about the client's mental state, it is not the priority intervention in this case. The client has already attempted suicide, indicating a high level of risk. It is essential to focus on ensuring the client's immediate safety before conducting further assessments.

Rationale for Choice B:

Making a contract with the client for eating behavior can be a helpful intervention for clients with anorexia nervosa. However, it is not the priority in the immediate aftermath of a suicide attempt. The client's safety must take precedence over addressing their eating disorder.

Rationale for Choice C:

Reviewing the client's toxicology laboratory report can provide information about the substances the client ingested in their suicide attempt. However, this information is not necessary for determining the immediate course of action. The priority is to initiate safety measures to prevent another attempt.

Rationale for Choice D:

Initiating one-to-one continuous observation is the most critical intervention for a client who has recently attempted suicide. This level of observation ensures that the client is constantly monitored and cannot make another attempt without being interrupted. It also allows the nurse to assess the client's mental state and behaviors closely and intervene if necessary.

A. Heart rate B. Respiratory rate C. Blood pressure D. Temperature.

Correct Answer is C

Explanation

Choice A rationale: While a heart rate of 52/min is lower than the normal range (60-100/min), it’s not uncommon in individuals with anorexia nervosa due to the body’s adaptation to conserve energy.

However, it’s not the most critical vital sign to address first in this scenario.

Choice B rationale: A respiratory rate of 26/min is slightly elevated (normal range is 12-20/min), possibly due to anxiety or distress.

However, it’s not the most immediate concern compared to other vital signs.

Choice C rationale: The client’s blood pressure is 84/50 mm Hg, which is significantly lower than the normal range (90/60 to 120/80 mm Hg). This could indicate hypotension, which can lead to dizziness, fainting, and inadequate blood flow to organs.

Hypotension is a common complication of anorexia nervosa due to decreased blood volume and weakened heart muscle.

Therefore, it should be addressed first.

Choice D rationale: The client’s temperature is 36.1°C (97°F), which is slightly lower than the normal body temperature range (36.5–37.5°C or 97.7–99.5°F). Hypothermia is a common complication in individuals with anorexia nervosa due to loss of body fat, which provides insulation.

However, it’s not the most immediate concern in this scenario.

In conclusion, the nurse should first address the client’s blood pressure due to the potential risks associated with hypotension.

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A nurse is caring for a client who has generalized anxiety disorder and is taking buspirone. Which of the following adverse effects should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following a suicide attempt.The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Correct Answer is D

Explanation

A nurse in a mental health unit is admitting a female client who has anorexia nervosa. The admission vital signs are as follows: Heart rate 52/min, Respiratory rate 26/min, Blood pressure 84/50 mm Hg, Temperature 36.1C(97F). The nurse should first address the client's:

Correct Answer is C

Explanation

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