Patient Data
Which assessment findings require follow-up by the nurse? Select all that apply.
Myoclonus
Temperature 102°F (38.8°C)
Blood pressure 168/94 mm Hg
Altered mental status
Heart rate 118 beats/minute
Respirations 16 breaths/minute
Capillary refill
Diaphoresis
Lung sounds.
Correct Answer : A,B,C,D,E,H
Choice A: Myoclonus
Myoclonus refers to sudden, involuntary muscle jerks. In the context of this patient’s presentation, myoclonus is significant because it can be a symptom of serotonin syndrome, a potentially life-threatening condition that can occur with the use of serotonergic medications like paroxetine. Serotonin syndrome is characterized by a triad of cognitive, autonomic, and somatic effects, including altered mental status, autonomic instability, and neuromuscular abnormalities such as myoclonus. Therefore, the presence of myoclonus in this patient warrants immediate follow-up to rule out serotonin syndrome and initiate appropriate treatment if necessary.
Choice B: Temperature 102°F (38.8°C)
A temperature of 102°F (38.8°C) is indicative of a fever, which is an abnormal finding that requires follow-up. Fever can be a sign of infection or other inflammatory processes. In the context of this patient’s symptoms, including altered mental status and myoclonus, a high fever could also be a sign of serotonin syndrome. Normal body temperature ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C). A temperature above this range is concerning and requires further investigation to determine the underlying cause and appropriate intervention.
Choice C: Blood Pressure 168/94 mm Hg
The patient’s blood pressure of 168/94 mm Hg is significantly elevated. Normal blood pressure for adults is typically around 120/80 mm Hg. Hypertension can be a sign of autonomic instability, which is another component of serotonin syndrome. Elevated blood pressure can also increase the risk of cardiovascular events such as stroke or heart attack. Therefore, this finding requires follow-up to manage the patient’s blood pressure and address any underlying causes.
Choice D: Altered Mental Status
Altered mental status is a broad term that encompasses changes in cognitive function, including confusion, disorientation, and altered levels of consciousness. This patient’s altered mental status, combined with other symptoms such as fever and myoclonus, raises concern for serotonin syndrome. Altered mental status can also be caused by other conditions such as infections, metabolic disturbances, or neurological disorders. Immediate follow-up is necessary to determine the cause and provide appropriate treatment.
Choice E: Heart Rate 118 beats/minute
A heart rate of 118 beats per minute is considered tachycardia, which is an abnormally fast heart rate. The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Tachycardia can be a sign of autonomic instability, which is seen in conditions like serotonin syndrome. It can also be caused by fever, dehydration, or other underlying conditions. Follow-up is required to assess the cause of the tachycardia and manage it appropriately.
Choice F: Respirations 16 breaths/minute
A respiratory rate of 16 breaths per minute is within the normal range for adults, which is typically 12 to 20 breaths per minute. Therefore, this finding does not require immediate follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms.
Choice G: Capillary Refill
Capillary refill time of less than 3 seconds is considered normal. This indicates that the patient’s peripheral perfusion is adequate. Therefore, this finding does not require follow-up. However, it is important to continue monitoring for any changes in perfusion status.
Choice H: Diaphoresis
Diaphoresis, or excessive sweating, is another symptom that requires follow-up. It can be a sign of autonomic instability and is commonly seen in serotonin syndrome. Diaphoresis can also be associated with other conditions such as infections, hyperthyroidism, or anxiety. Given the patient’s other symptoms, it is important to investigate the cause of the diaphoresis and address it as part of the overall management plan.
Choice I: Lung Sounds
Lung sounds are noted to be clear, which is a normal finding. This indicates that there are no immediate respiratory issues such as pneumonia or pulmonary edema. Therefore, this finding does not require follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Nausea is a common side effect of many medications, including metoclopramide. While it is important to monitor, it is not the most critical adverse effect to report. Metoclopramide is often prescribed to manage nausea, so experiencing this symptom may indicate the need for dosage adjustment or additional supportive care, but it is not an emergency.
Choice B Reason:
Diarrhea is another common side effect of metoclopramide. It can be uncomfortable and may require management, but it is not typically life-threatening. The nurse should monitor the client and provide supportive care, but this side effect does not necessitate immediate reporting unless it becomes severe or persistent.
Choice C Reason:
Unusual irritability can occur with metoclopramide use. While it is important to note changes in mood or behavior, this symptom is not as critical as some other potential adverse effects. The nurse should monitor the client and consider discussing this symptom with the healthcare provider, but it is not the most urgent concern.
Choice D Reason:
Involuntary movements, such as those seen in tardive dyskinesia, are a serious adverse effect of metoclopramide. Tardive dyskinesia is a potentially irreversible condition characterized by repetitive, involuntary movements, often of the face and tongue. This side effect is significant and requires immediate reporting to the healthcare provider, as it may necessitate discontinuation of the medication and further evaluation.
Correct Answer is B
Explanation
Choice A Reason:
Photosensitivity is not a common side effect of gabapentin. While some medications can cause increased sensitivity to sunlight, gabapentin is not typically associated with this issue. Therefore, it is not a primary concern that needs to be reported to the healthcare provider.
Choice B Reason:
Rapid weight gain is a significant side effect that should be reported to the healthcare provider. Gabapentin can cause fluid retention and swelling, which may lead to rapid weight gain. This can be a sign of more serious underlying issues, such as heart or kidney problems, and requires prompt medical attention.
Choice C Reason:
Gastric irritation, such as nausea or upset stomach, can occur with gabapentin use but is generally not severe. While it can be uncomfortable, it is usually manageable with supportive care and does not typically require immediate reporting to a healthcare provider unless it becomes severe or persistent.
Choice D Reason:
Sexual dysfunction is not commonly associated with gabapentin. While some medications can affect sexual function, gabapentin’s side effects are more commonly related to the nervous system, such as dizziness, drowsiness, and coordination issues. Therefore, this is not a primary concern that needs to be reported.
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