A nurse is caring for a client who is exhibiting severe manifestations of serotonin syndrome. Which of the following is the priority nursing intervention?
Padding side rails to prevent injury.
Applying a cooling blanket.
Administering an anticonvulsant.
Preparing for artificial ventilation.
The Correct Answer is D
While preventing injury is important, it is not the highest priority when the client's respiratory and neurological functions are compromised. Managing the client's breathing takes precedence.
B. Applying a cooling blanket.
While hyperthermia (high fever) is a symptom of serotonin syndrome, the immediate concern is ensuring the client's breathing and neurological stability. Cooling measures can be beneficial, but they come after addressing the more critical issues.
C. Administering an anticonvulsant.
While anticonvulsants might be used to control seizures, preparing for artificial ventilation takes priority, as the client's airway and oxygenation must be secured before addressing other symptoms.
D. Preparing for artificial ventilation.
Explanation: Serotonin syndrome is a potentially life-threatening condition caused by an excess of serotonin in the body, often resulting from interactions between medications that affect serotonin levels. Severe manifestations of serotonin syndrome can include high fever, muscle rigidity, agitation, seizures, and even coma. In cases of severe serotonin syndrome, the client's neurological and respiratory functions can be compromised, making it crucial to ensure adequate ventilation and oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. An adolescent client who throws objects at other clients:
Explanation: Seclusion is contraindicated for this client due to safety concerns. The behavior of throwing objects at others indicates a potential danger to both the client and others in a confined space. Placing the client in seclusion could escalate the situation and potentially lead to further harm.
B. An older adult client who is manic and crying due to overstimulation:
Explanation: Seclusion might be contraindicated for this client as well. Older adults experiencing manic behavior and emotional distress could be further traumatized by seclusion. Alternatives like providing a calm and soothing environment, along with appropriate medications, might be more beneficial for this client.
C. A school-age client who attempts to repeatedly bite staff:
Explanation: Seclusion is a potential option for this client. The repeated attempts to bite staff pose a risk of physical harm to both the client and staff members. Seclusion might be used as a last resort to ensure the safety of everyone involved.
D. An adult client following a suicide attempt:
Explanation: Seclusion is generally contraindicated for clients who have attempted suicide. Placing them in isolation can worsen feelings of despair and isolation, potentially increasing the risk of self-harm or suicide. These clients require close monitoring, support, and therapeutic interventions to address the underlying issues.
Correct Answer is ["0.75"]
Explanation
To calculate the volume (ml) of haloperidol decanoate needed for a dose of 75 mg, you can use the following formula:
Volume (ml) = Dose (mg) / Concentration (mg/ml)
Given:
Dose = 75 mg
Concentration = 100 mg/ml
Plugging in the values:
Volume (ml) = 75 mg / 100 mg/ml
Volume (ml) = 0.75 ml
Rounding to the nearest hundredth:
Volume (ml) = 0.75 ml
So, the nurse should administer 0.75 ml of haloperidol decanoate for the dose of 75 mg.
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