A client diagnosed with anorexia nervosa is newly admitted to an inpatient psychiatric unit. Which nursing intervention takes priority?

Assessment of family health history

Assessment of the client’s knowledge of treatment options

Assessment of early disturbance in family interactions

Assessment and monitoring of vital signs and lab values

Answer and Explanation

The Correct Answer is D

Choice A reason: Assessing family health history may provide context for genetic predispositions to mental health disorders. However, it is not the priority upon admission, as it does not address immediate physiological risks like malnutrition or cardiac instability, which are critical in anorexia nervosa due to severe weight loss.

Choice B reason: Assessing the client’s knowledge of treatment options is important for engaging them in their care plan. However, this is secondary to addressing immediate physical health risks, such as electrolyte imbalances or cardiac complications, which are life-threatening in anorexia nervosa and require urgent attention.

Choice C reason: Assessing early disturbances in family interactions may help identify triggers for anorexia nervosa, such as emotional stress. However, this is not the priority upon admission, as it does not address the immediate physiological dangers of malnutrition, dehydration, or organ dysfunction, which take precedence.

Choice D reason: Anorexia nervosa can cause severe physiological complications, including bradycardia, hypotension, and electrolyte imbalances, due to malnutrition. Assessing and monitoring vital signs and lab values is critical to identify life-threatening conditions like hypokalemia or cardiac arrhythmias, ensuring immediate stabilization and guiding treatment, making it the priority intervention.

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Correct Answer is C

Explanation

Choice A reason: Impotence is a potential side effect of SSRIs due to serotonin’s effect on sexual function but is not a symptom of serotonin syndrome, a life-threatening condition involving excessive serotonin causing hyperthermia, agitation, and muscle rigidity, making this incorrect.

Choice B reason: Hypotension is not a primary symptom of serotonin syndrome, which involves serotonin excess leading to hyperthermia, tremors, and autonomic instability. Hypotension may occur secondary to severe cases but is not a hallmark symptom included in teaching.

Choice C reason: Fever is a key symptom of serotonin syndrome, caused by excessive serotonin stimulation leading to hyperthermia, muscle rigidity, and autonomic dysfunction. It’s a critical teaching point, as it signals a medical emergency requiring immediate intervention to prevent organ damage.

Choice D reason: Constipation is a side effect of some SSRIs due to serotonin’s effect on gastrointestinal motility but is not associated with serotonin syndrome. This condition involves acute neurological and autonomic symptoms, not chronic gastrointestinal issues, making this incorrect.

A. Strong or aged cheese should not be eaten while taking them B. Its full therapeutic potential may not be reached until 4-6 weeks C. They should not be given with antianxiety agents D. It may cause hypomania, weight gain, and an increase in sleep

Correct Answer is B

Explanation

Choice A reason: Avoiding strong or aged cheese applies to MAOIs due to tyramine interactions causing hypertensive crises. Most antidepressants, like SSRIs or SNRIs, do not require this dietary restriction, as they do not affect monoamine oxidase, making this information incorrect.

Choice B reason: Antidepressants, such as SSRIs, typically require 4-6 weeks to achieve full therapeutic effects by increasing neurotransmitter levels (serotonin, norepinephrine) in the brain. This delay is critical for patient expectations and adherence, making this the most appropriate information to provide.

Choice C reason: Antidepressants can be safely combined with antianxiety agents, such as benzodiazepines, under medical supervision for co-occurring anxiety and depression. This statement is incorrect, as combination therapy is common and does not require avoidance, depending on the clinical context.

Choice D reason: Hypomania, weight gain, and increased sleep are possible side effects of some antidepressants (e.g., mirtazapine), but they are not universal. SSRIs may cause insomnia or weight loss, making this information less broadly applicable than the therapeutic delay information.

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A client diagnosed with anorexia nervosa is newly admitted to an inpatient psychiatric unit. Which nursing intervention takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client was admitted to the inpatient unit for depression and is prescribed a selective serotonin reuptake inhibitor (SSRI). Which sign or symptom would the nurse include in the teaching session about serotonin syndrome?

Correct Answer is C

Explanation

A nurse is educating a patient who has been prescribed an antidepressant for depression. Which of the following is the most appropriate information for the nurse to provide?

Correct Answer is B

Explanation

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