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":"C","dropdown-group-2":"C"}
The client is at risk for developing serotonin syndrome due to adverse effects of paroxetine.
Rationale:
Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonergic activity, often from SSRIs or interactions with other serotonergic medications.
This client recently had fluoxetine discontinued and paroxetine started at 10 mg, then increased to 30 mg daily. Rapid dose increases or overlapping serotonergic effects increase the risk of serotonin syndrome.
Manifestations such as restlessness, abdominal pain, disorientation, and fever are classic early signs of serotonin syndrome.
Mania: There is no history of bipolar disorder or manic episodes; current symptoms are not consistent with mania.
Psychosis: No hallucinations, delusions, or disorganized thinking noted, making psychosis less likely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","E"]
Explanation
A. Clients with C. difficile require dedicated equipment (e.g., thermometers, stethoscopes) that is not shared to prevent cross-contamination.
B. C. difficile is transmitted via spores that contaminate surfaces and clothing; a gown is required for contact precautions.
C. Alcohol-based hand rubs are ineffective against C. difficile spores. Hands must be washed with soap and water.
D. An N95 respirator is required only for airborne precautions (e.g., tuberculosis), not C. difficile.
E. Gloves must be changed after contact with infectious material and between procedures to prevent spore transmission.
Correct Answer is ["A","C","D","I"]
Explanation
A. Perform daily weights: Daily weights are important to monitor progress and detect fluid or nutritional changes. This routine, non-invasive task is appropriate for delegation to assistive personnel (AP) under nurse supervision.
B. Identify thoughts that reinforce disordered eating patterns: Requires therapeutic communication and assessment, which are nursing responsibilities. Not appropriate for delegation to AP.
C. Accompany the client to the restroom following meals: Clients with bulimia are at risk of vomiting or purging after eating. Having an AP accompany the client helps prevent self-induced vomiting and ensures compliance with the treatment plan. The AP should report any unusual behavior to the nurse.
D. Observe the client during meals: Monitoring during meals ensures the client eats appropriately and avoids concealing or discarding food. This is a behavioral safety measure that can be delegated, while the nurse focuses on therapeutic interventions.
E. Consult the dietitian to determine the client’s caloric intake: Consulting other team members is a nursing role, involving coordination of interdisciplinary care.
F. Use cognitive behavioral techniques to address the client’s behavior: CBT and psychotherapy require specialized knowledge and are conducted by nurses or mental health professionals, not assistive personnel.
G. Discuss measures to assist the client to develop a positive body image: Involves therapeutic communication and counseling, not within the AP’s scope.
H. Encourage the client to discuss feelings of new eating patterns: Addressing emotions and behavioral change is a therapeutic intervention requiring nursing judgment.
I. Check the client’s vital signs: Vital signs provide data about orthostatic hypotension, dehydration, or arrhythmia risk. The AP can collect this data, while the nurse evaluates and interprets the results.
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