An outpatient client taking paroxetine states he started taking St. John's Wort. The client calls the nurse with complaints of a high fever, muscle stiffness, and sweating. The nurse should advise the client to

use a high-quality heating pad for the pain.

contact the primary care provider immediately.

call an orthopedic doctor to evaluate the symptoms.

start on a clear liquid diet and maintain bedrest.

Answer and Explanation

The Correct Answer is B

B. The combination of paroxetine and St. John's Wort can lead to a potentially life-threatening condition known as serotonin syndrome. It is important for healthcare providers to be aware of potential drug interactions and to monitor patients closely when changes to their medication regimen occur.
A. Using a heating pad may provide temporary relief for muscle stiffness but does not address the underlying cause of the symptoms.
C. Given the symptoms described, involving an orthopedic doctor is not appropriate as the symptoms are not related to musculoskeletal issues.
D. A clear liquid diet and bed rest do not address the underlying issue in the client hence not an appropriate action.

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Correct Answer is C

Explanation

C. Individuals with borderline personality disorder often struggle with intense emotions and may engage in self-harming behaviors as a maladaptive coping mechanism. Helping the client identify triggers for their distress and teaching them alternative coping strategies, such as mindfulness, grounding techniques, or distress tolerance skills, can empower them to manage their emotions in healthier ways.
A. Anxiolytic medications can help alleviate anxiety symptoms but they are not typically the first-line intervention for addressing acute distress in individuals with borderline personality disorder (BPD).
B. Restraint should not be the first response to a client expressing distress or suicidal ideation. Physical restraint should only be used as a last resort in situations where there is an imminent risk of harm to the client or others and should be implemented by trained professionals following established protocols.
D. Encouraging self-harm behaviors reinforces maladaptive coping strategies and can increase the risk of harm to the client. It is essential to provide support and interventions aimed at reducing self-harming behaviors.

A. is not responding to other clients on the unit. B. angrily argues with another client stating, "God is dead." C. is refusing to take his prescribed mood stabilizer. D. states, "There is no future when you feel so depressed."

Correct Answer is D

Explanation

D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.

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An outpatient client taking paroxetine states he started taking St. John's Wort. The client calls the nurse with complaints of a high fever, muscle stiffness, and sweating. The nurse should advise the client to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with borderline personality disorder reported to the nurse in the clinic that they feel empty and anxious and wants to cut their arms. The nurse should:

Correct Answer is C

Explanation

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

Correct Answer is D

Explanation

The nurse is planning a psycho-education group for clients diagnosed with borderline personality disorder. The nurse understands that which aspect of group intervention is most essential initially to establish a trusting nurse-patient relationship?

The nurse working with a teen, who has a history of being moody and withdrawn, will make the establishment of a therapeutic alliance a priority because:

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