The nurse has reviewed the Provider Orders from 2 weeks ago.

The nurse is reinforcing teaching about the newly prescribed medication with the adolescent and their guardian. Which of the following information should the nurse include? Select all that apply.

"Sweating is a potential side effect of this medication.

"This medication affects serotonin levels."

"This medication may cause mild nausea."

"Orange-colored urine is a potential side effect of this medication."

"Avoid consuming aged cheeses while taking this medication.

"This medication should not be taken within 1 hour of a high-fat meal."

Answer and Explanation

Correct Answer : A,B,C

A. "Sweating is a potential side effect of this medication.": Sertraline, a selective serotonin reuptake inhibitor (SSRI), can increase sympathetic nervous system activity, leading to side effects such as sweating (diaphoresis). Clients should be informed to monitor and report excessive sweating.

B. "This medication affects serotonin levels.": Sertraline works by inhibiting the reuptake of serotonin in the brain, increasing its availability at synaptic clefts. This mechanism helps improve mood, anxiety, and obsessive-compulsive behaviors associated with anorexia nervosa.

C. "This medication may cause mild nausea.": Gastrointestinal disturbances, including nausea, diarrhea, or upset stomach, are common early side effects of sertraline. These effects are usually mild and transient as the body adjusts to the medication.

D. "Orange-colored urine is a potential side effect of this medication.": Orange urine is not associated with sertraline. This effect is more typical of medications such as rifampin or phenazopyridine.

E. "Avoid consuming aged cheeses while taking this medication.": Dietary restrictions related to tyramine-containing foods, like aged cheeses, are necessary with monoamine oxidase inhibitors (MAOIs), not SSRIs like sertraline.

F. "This medication should not be taken within 1 hour of a high-fat meal.": Sertraline absorption is not significantly affected by food intake, including high-fat meals. No timing restrictions with meals are generally required.

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Correct Answer is ["B","E"]

Explanation

A. Compulsive behaviors: The adolescent continues to pace, fold and unfold blankets, and engage in rigid organizing behaviors, indicating that compulsive behaviors are still present and have not yet improved.

B. BMI: The adolescent’s BMI increased from 16.1 (4th percentile) to 16.8 (9th percentile), reflecting weight gain and improvement in nutritional status, which is a positive clinical outcome in the treatment of anorexia nervosa.

C. Sleep: The adolescent slept little overnight and was awake frequently, showing that sleep disturbances persist. No improvement in sleep patterns is evident at this time.

D. Temperature: The adolescent’s temperature remains low at 35.8° C (96.4° F) two weeks ago and no updated reading shows normalization, indicating hypothermia has not resolved.

E. Heart rate: The heart rate improved from 48/min two weeks ago to 60–70/min today (assuming 41.7 kg weight), reflecting improved cardiovascular stability and physiologic recovery from malnutrition.

A. Remove the client's dentures from their mouth before rigor mortis begins. B. Position the client's bed flat without a pillow under their head. C. Turn on all the lights in the room before the family views the client's body. D. Ask the client's family about cultural or religious practices regarding postmortem care.

Correct Answer is D

Explanation

A. Remove the client's dentures from their mouth before rigor mortis begins: Dentures should generally remain in place to maintain facial structure and a natural appearance for the family. Removing them is not required unless specified by the family or institutional policy.

B. Position the client's bed flat without a pillow under their head: The head should typically be elevated slightly to reduce facial discoloration and promote a natural appearance. Placing the body flat without a pillow is not standard postmortem practice.

C. Turn on all the lights in the room before the family views the client's body: Bright lighting is unnecessary and may be distressing. Soft, appropriate lighting is preferred to create a calm environment for family members.

D. Ask the client's family about cultural or religious practices regarding postmortem care: Cultural and religious considerations are essential in postmortem care. Asking the family ensures that care aligns with their beliefs and provides respectful, individualized support during a sensitive time.

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Body System	Findings
Cardiovascular	Heart rhythm irregular. No murmurs noted. Blood pressure 80/50 mm Hg
Gastrointestinal	Abdomen soft and nontender to palpation. Hypoactive bowel sounds.
Height/Weight	Height 157.5 cm (62 in) Weight 39.9 kg (88 lb) BMI 16.1 (4th percentile)
Behavioral	Guardian states. "They have always been a good kid. They have never been in trouble or anything." Also reports exercising a lot and will run up and down the stairs when guardians are not home.

The nurse has reviewed the Provider Orders from 2 weeks ago. The nurse is reinforcing teaching about the newly prescribed medication with the adolescent and their guardian. Which of the following information should the nurse include? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse has reviewed today's Vital Signs and Provider's Orders Select the 2 findings that indicate an improvement in the adolescent's condition.

Correct Answer is ["B","E"]

Explanation

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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The nurse has reviewed the Provider Orders from 2 weeks ago.

The nurse is reinforcing teaching about the newly prescribed medication with the adolescent and their guardian. Which of the following information should the nurse include? Select all that apply.