Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Administer 2 mg of diazepam intravenously.

Induce paralysis.

Apply cooling blankets.

Apply 1 L/min oxygen.

Ensure that the antidepressant medication is discontinued

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}

Diazepam is a benzodiazepine that can be effective in managing symptoms of serotonin syndrome, including agitation and myoclonus. It can help reduce muscle rigidity and provide sedation.

Inducing paralysis is not appropriate in this scenario. The patient’s symptoms suggest serotonin syndrome or another type of stimulant intoxication, and paralysis could worsen the situation or mask underlying symptoms.

The patient has a high fever (102°F or 38.8°C) and significant diaphoresis. Cooling blankets can help manage hyperthermia and reduce body temperature.

The patient’s oxygen saturation is 97% on room air, indicating adequate oxygenation. There is no immediate need for supplemental oxygen at this time.

If the patient is suspected to have serotonin syndrome, which can be triggered by the use of certain antidepressants (particularly SSRIs), discontinuing the offending medication is crucial.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

A. Ask the client for a description of the exercise schedule that is being followed. B. Encourage the client to exercise every day to eliminate bedtime wakefulness. C. Advise the client that lifestyle changes often take several weeks to be effective. D. Determine the amount of weight the client has lost since increasing activity.

Correct Answer is A

Explanation

A. Understanding the exercise schedule can help the nurse determine if the timing or type of exercise is contributing to sleep issues.

B. Exercising every day can be beneficial, but the timing of exercise (e.g., too close to bedtime) can impact sleep.

C. While lifestyle changes do take time, the nurse should first assess the current exercise habits to provide tailored advice.

D. Weight loss is an important outcome but does not directly address the sleep issue.

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Patient Data Exhibits The nurse reviews the prescriptions and assessment data. Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is B

Explanation

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

Correct Answer is A

Explanation

An older adult client is brought to the clinic for Increased confusion over the past three days and presents with a draining wound on the right leg. Which assessment is most important for the nurse to obtain?

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day? (Enter numeric value only.)

A client with deep vein thrombosis (DVT) is receiving a continuous intravenous heparin infusion. The client now has tarry, black diarrhea and reports abdominal pain. Which actions should the nurse implement? Select all that apply.

Patient Data

Exhibits

The nurse reviews the prescriptions and assessment data.

Click to indicate which interventions could help reduce symptoms if added to the plan of care. Each row must have one response option selected.