A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations.
What is the priority action?
Ask if the patient has started any new prescription or over-the-counter medications.
Administer an anti-anxiety medication to subdue and sedate the patient.
Place the patient in loose bilateral arm restraints.
Tell the patient that the voices they are hearing are not real.
The Correct Answer is A
This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.
Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.
Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.
Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Clubbing in upper digits and tripod positioning are signs of chronic obstructive pulmonary disease (COPD), a respiratory disorder that has components of chronic bronchitis and emphysema. Clubbing is a thickening and widening of the fingertips and nails due to chronic low oxygen levels in the blood. Tripod positioning is when the person leans forward and supports their arms on a table or chair to facilitate breathing.
Choice A is wrong because a BMI greater than 30% indicates obesity, which is not a specific sign of COPD, although it can worsen the condition.
Choice C is wrong because AP chest diameter of 1:1 means that the chest is as wide as it is deep, which is also known as barrel chest. This is a sign of emphysema, one of the components of COPD, but not of COPD itself.
Choice E is wrong because high amounts of energy are not associated with COPD. On the contrary, people with COPD often experience fatigue, weakness, and reduced exercise tolerance due to impaired gas exchange and respiratory muscle function.
Correct Answer is C
Explanation
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
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