A charge nurse in an emergency department is assigning tasks. Which off the following tasks should the nurse delegate to an assistive personnel?

Transfer a client who has delirium from a bed to a wheelchair.

Inform a client who has schizophrenia about available community services.

Obtain a list of current medications from a client who is experiencing a manic episode.

Insert an NG tube for a client who has acetaminophen toxicity.

Answer and Explanation

The Correct Answer is A

A. Transfer a client who has delirium from a bed to a wheelchair: Assisting with transfers and mobility is within the scope of practice for an AP, especially if the client is stable and the task does not require clinical decision-making.

B. Inform a client who has schizophrenia about available community services: This task requires clinical judgment and communication skills to ensure that the client understands the information and that the services are appropriate for their needs. It should be performed by a nurse, not an AP.

C. Obtain a list of current medications from a client who is experiencing a manic episode: While obtaining a medication list is an important task, it requires assessment and evaluation of the client's condition, which should be done by a nurse, especially when the client is in a manic state and may have impaired judgment or communication.

D. Insert an NG tube for a client who has acetaminophen toxicity: Inserting an NG tube is an invasive procedure that requires clinical knowledge and skill. It should be performed by a licensed nurse or physician, not an AP.

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Correct Answer is A

Explanation

A. Decrease in blood pressure: A decrease in blood pressure is a positive sign that the treatment for serotonin syndrome is effective. Treatment typically includes discontinuing the causative medication and providing supportive care to normalize vital signs, including blood pressure.

B. Muscle rigidity: Muscle rigidity is a hallmark sign of serotonin syndrome and indicates that the condition is still present or not yet effectively treated. Successful treatment should reduce muscle rigidity over time.

C. Hyperreflexia: Hyperreflexia (overactive reflexes) is also a common symptom of serotonin syndrome. If the treatment is effective, hyperreflexia should resolve as serotonin levels normalize in the body.

D. Altered mental status: Altered mental status is another indicator of serotonin syndrome. Improvement in serotonin syndrome would be evidenced by a return to normal cognitive function, so persistence of altered mental status suggests that treatment has not yet been fully effective.

A. A client who is taking venlafaxine and exhibits frequent yawning and weight loss B. A client who is taking olanzapine and reports frequent urination C. A client who is taking fluoxetine and exhibits muscle rigidity and tachycardia D. A client who is taking nortriptyline and reports nausea and dry mouth

Correct Answer is C

Explanation

A. Venlafaxine and frequent yawning/weight loss: Frequent yawning and weight loss are not typical signs of an adverse reaction to venlafaxine. These symptoms can occur with various conditions, but they do not necessarily require withholding the medication.
B. Olanzapine and frequent urination: Frequent urination is not a known side effect of olanzapine. However, the nurse should assess the client for other factors contributing to this symptom. It may not be severe enough to require withholding the medication without further evaluation.
C. Fluoxetine and muscle rigidity/tachycardia: Muscle rigidity and tachycardia could indicate serotonin syndrome, a potentially life-threatening condition. This requires immediate intervention, and the medication should be withheld while notifying the provider for further evaluation and treatment.
D. Nortriptyline and nausea/dry mouth: Nausea and dry mouth are common side effects of tricyclic antidepressants like nortriptyline. These symptoms typically do not require withholding the medication, but the nurse should monitor the client for any worsening or additional adverse effects.

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A charge nurse in an emergency department is assigning tasks. Which off the following tasks should the nurse delegate to an assistive personnel?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client following treatment for serotonin syndrome caused by an antidepressant medication. Which of the following findings indicates the treatment has been effective?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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