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 A
Explanation
Do not eat or drink for 12 hours prior to the test. This is because fasting is required for a total serum cholesterol test to get accurate results. Fasting means not eating or drinking anything except water for 9 to 12 hours before the test.
Choice B is wrong because eliminating all dietary cholesterol for one week before the test is not necessary and will not affect the test results. Dietary cholesterol only accounts for a small portion of the total cholesterol in the blood.
Choice C is wrong because avoiding caffeinated beverages for several days prior to the test is not required and will not influence the test results. Caffeine does not affect cholesterol levels.
Choice D is wrong because stopping eating eggs and drinking milk for two days before the test is not needed and will not change the test results. Eggs and milk contain cholesterol, but they also have other nutrients that may lower the risk of heart disease.
Normal ranges for total serum cholesterol are less than 200 mg/dL (5.18 mmol/L) for adults. Higher levels may indicate an increased risk of heart disease and stroke.
Correct Answer is A
Explanation
This is because the first priority for assessing an elderly client who has become confused since admission is to rule out hypoxia, which can cause or worsen delirium. Hypoxia can result from various conditions, such as pneumonia, pulmonary embolism, or heart failure.
Oxygen saturation measurement is a quick and non-invasive way to assess the oxygen level in the blood and identify hypoxia.
Choice B. Review of current medications is wrong because although medications can cause or contribute to confusion and delirium in older adults, they are not the most urgent assessment to perform.
Medications should be reviewed after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice C. Intake and output last 24 hours is wrong because although dehydration and electrolyte imbalance can cause or worsen confusion and delirium in older adults, they are not the most urgent assessment to perform.
Intake and output should be monitored after ensuring adequate oxygenation and addressing other possible causes of confusion.
Choice D. Use of hearing aids or glasses is wrong because although sensory impairment can cause or worsen confusion and delirium in older adults, it is not the most urgent assessment to perform.
The use of hearing aids or glasses should be ensured after ensuring adequate oxygenation and addressing other possible causes of confusion.
Normal ranges for oxygen saturation are 95% to 100% for healthy adults. Lower levels may indicate hypoxia or other respiratory or cardiac problems.
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